MEDICARE: MS. EDITH N AGBOR BS

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	172A00000X	Driver	12523069	TX

General Provider Information

NPI Number	:	1780886135
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. EDITH N AGBOR BS

Provider Business Mailing Address
First Line	:	9330 AMBERTON PKWY
Second Line	:	SUITE 1135
City	:	DALLAS
State	:	TX
Zip	:	75243-3278
Country	:	US
Telephone Number	:	972-331-9120
Fax Number	:	972-331-9121

Provider Business Practice Location Address
First Line	:	9330 AMBERTON PKWY
Second Line	:	SUITE 1135
City	:	DALLAS
State	:	TX
Zip	:	75243-3278
Country	:	US
Telephone Number	:	972-331-9120
Fax Number	:	972-331-9121

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

Provider Enumeration Date	:	06/05/2007
Last Update Date	:	07/08/2007

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