MEDICARE: DIRECT PRIMARY CARE IN TEXAS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	261QM0850X	Adult Mental Health Clinic/Center
2	261QM0855X	Adolescent and Children Mental Health Clinic/Center
3	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1942806773
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIRECT PRIMARY CARE IN TEXAS LLC

Provider Business Mailing Address
First Line	:	7311 S HULEN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-6616
Country	:	US
Telephone Number	:	817-349-9228
Fax Number	:

Provider Business Practice Location Address
First Line	:	7311 S HULEN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-6616
Country	:	US
Telephone Number	:	817-349-9228
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MICHELE GRAHAM
Credential	:
Telephone Number	:	817-349-9228

Provider Enumeration Date	:	12/08/2020
Last Update Date	:	02/08/2023

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