MEDICARE: ELEVATION EP, LLC

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	174400000X	Specialist

General Provider Information

NPI Number	:	1740771211
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELEVATION EP, LLC

Provider Business Mailing Address
First Line	:	201 MAIN STREET
Second Line	:	SUITE 600
City	:	FT. WORTH
State	:	TX
Zip	:	76102-3105
Country	:	US
Telephone Number	:	817-270-0384
Fax Number	:	817-270-0384

Provider Business Practice Location Address
First Line	:	201 MAIN STREET
Second Line	:	SUITE 600
City	:	FT. WORTH
State	:	TX
Zip	:	76102-3105
Country	:	US
Telephone Number	:	817-270-0384
Fax Number	:	817-270-0384

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. DARLENE HOLDER
Credential	:
Telephone Number	:	817-368-1980

Provider Enumeration Date	:	05/21/2018
Last Update Date	:	05/21/2018

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