MEDICARE: TARRANT COUNTY MEDICAL INSTITUTE, P.A.

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	111N00000X	Chiropractor		TX
2	207Q00000X	Family Medicine Physician		TX

General Provider Information

NPI Number	:	1699969865
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TARRANT COUNTY MEDICAL INSTITUTE, P.A.

Provider Business Mailing Address
First Line	:	6789 CAMP BOWIE BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-7112
Country	:	US
Telephone Number	:	817-731-2102
Fax Number	:	817-984-1857

Provider Business Practice Location Address
First Line	:	6789 CAMP BOWIE BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-7112
Country	:	US
Telephone Number	:	817-731-2102
Fax Number	:	817-984-1857

Authorized Official
Title or Position	:	BUSINESS MGR
Name	:	SANDRA L FLETCHER
Credential	:
Telephone Number	:	214-616-4892

Provider Enumeration Date	:	08/30/2007
Last Update Date	:	05/10/2017

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