MEDICARE: FORT WORTH NORTHSIDE COMMUNITY HEALTH CENTER

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	251V00000X	Voluntary or Charitable Agency

General Provider Information

NPI Number	:	1730182585
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT WORTH NORTHSIDE COMMUNITY HEALTH CENTER

Provider Business Mailing Address
First Line	:	2100 N MAIN ST
Second Line	:	STE 215
City	:	FORT WORTH
State	:	TX
Zip	:	76106-8576
Country	:	US
Telephone Number	:	817-378-0855
Fax Number	:	817-378-0861

Provider Business Practice Location Address
First Line	:	2106 N. MAIN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76106-8570
Country	:	US
Telephone Number	:	817-625-4254
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MR. EDDY L. HERRERA
Credential	:	MSSW
Telephone Number	:	817-378-0855

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	08/22/2020

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