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NPI Code Detail

MEDICARE: EDDIE ELLIS JUNIOR HCS

MEDICARE: EDDIE ELLIS JUNIOR HCS
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
1320600000XIntellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number : 1932346210
Entity Type Code : Organization
Provider Name (Legal Business Name) : EDDIE ELLIS JUNIOR HCS
Provider Business Mailing Address
First Line : 420 TIERNEY RD
Second Line :
City : FORT WORTH
State : TX
Zip : 76112-6324
Country : US
Telephone Number : 817-534-5480
Fax Number : 817-534-4748
Provider Business Practice Location Address
First Line : 420 TIERNEY RD
Second Line :
City : FORT WORTH
State : TX
Zip : 76112-6324
Country : US
Telephone Number : 817-534-5480
Fax Number : 817-534-4748
Authorized Official
Title or Position : CEO
Name : EDDIE ELLIS
Credential :
Telephone Number : 817-534-5480
Provider Enumeration Date : 01/08/2009
Last Update Date : 01/08/2009

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Directions to “EDDIE ELLIS JUNIOR HCS ” Practice Location

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