MEDICARE: DAVID LEON MIMS

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	261QA0600X	Adult Day Care Clinic/Center		TX

General Provider Information

NPI Number	:	1720515059
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID LEON MIMS

Provider Business Mailing Address
First Line	:	1412 ROMA LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76134-2304
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1412 ROMA LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76134-2304
Country	:	US
Telephone Number	:	682-583-4545
Fax Number	:

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

Provider Enumeration Date	:	05/17/2017
Last Update Date	:	06/16/2018

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Directions to “ DAVID LEON MIMS ” Practice Location

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