MEDICARE: VANZANELL EDWARDS ADMINISTOR

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	261QM0850X	Adult Mental Health Clinic/Center	136989	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	75-2645166	OTHER	TX	ADMINISTOR

General Provider Information

NPI Number	:	1831529080
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VANZANELL EDWARDS ADMINISTOR

Provider Business Mailing Address
First Line	:	7801 MARLBOROUGH DR W
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76134-4309
Country	:	US
Telephone Number	:	817-568-1445
Fax Number	:	817-782-9304

Provider Business Practice Location Address
First Line	:	7801 MARLBOROUGH DR W
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76134-4309
Country	:	US
Telephone Number	:	817-568-1445
Fax Number	:	817-782-9304

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

Provider Enumeration Date	:	11/24/2013
Last Update Date	:	11/24/2013

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