MEDICARE: CLINICAL NEUROSCIENCE PA

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	2084N0400X	Neurology Physician		TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760459671
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLINICAL NEUROSCIENCE PA

Provider Business Mailing Address
First Line	:	1307 8TH AVE STE 608
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4109
Country	:	US
Telephone Number	:	817-921-4191
Fax Number	:	817-926-6048

Provider Business Practice Location Address
First Line	:	1307 8TH AVE STE 608
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4140
Country	:	US
Telephone Number	:	817-921-4191
Fax Number	:	817-926-6048

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	TERESA R HERNANDEZ
Credential	:
Telephone Number	:	817-921-4191

Provider Enumeration Date	:	03/01/2006
Last Update Date	:	05/15/2023

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Directions to “CLINICAL NEUROSCIENCE PA ” Practice Location

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