MEDICARE: CLINICA HISPANA DEL METROPLEX 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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1912655721
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLINICA HISPANA DEL METROPLEX LLC

Provider Business Mailing Address
First Line	:	2741 ELLIS AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76164-7131
Country	:	US
Telephone Number	:	817-386-9926
Fax Number	:	817-386-9907

Provider Business Practice Location Address
First Line	:	2741 ELLIS AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76164-7131
Country	:	US
Telephone Number	:	817-386-9926
Fax Number	:	817-386-9907

Authorized Official
Title or Position	:	NP-C
Name	:	YENNYS RODRIGUEZ ALONSO
Credential	:	APRN-CNP
Telephone Number	:	214-991-5536

Provider Enumeration Date	:	03/11/2022
Last Update Date	:	03/11/2022

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