MEDICARE: BYRON BERRY

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	343900000X	Non-emergency Medical Transport (VAN)
2	347C00000X	Private Vehicle

General Provider Information

NPI Number	:	1770213464
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BYRON BERRY

Provider Business Mailing Address
First Line	:	18211 KELLY BLVD APT 1313
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75287-4639
Country	:	US
Telephone Number	:	205-370-4147
Fax Number	:

Provider Business Practice Location Address
First Line	:	18211 KELLY BLVD APT 1313
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75287-4639
Country	:	US
Telephone Number	:	205-370-4147
Fax Number	:

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

Provider Enumeration Date	:	06/15/2022
Last Update Date	:	06/15/2022

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