MEDICARE: MRS. TOMMIE NELL DAVIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility		TX

General Provider Information

NPI Number	:	1689811135
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TOMMIE NELL DAVIS

Provider Business Mailing Address
First Line	:	PO BOX 6691
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76115-0691
Country	:	US
Telephone Number	:	817-238-3961
Fax Number	:

Provider Business Practice Location Address
First Line	:	1521 SUNNY GLEN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76134-4853
Country	:	US
Telephone Number	:	817-238-3961
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2009
Last Update Date	:	01/20/2009

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