MEDICARE: REGINA THOMAS

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	1744P3200X	Prosthetics Case Management

General Provider Information

NPI Number	:	1972124972
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REGINA THOMAS

Provider Business Mailing Address
First Line	:	4364 WESTERN CENTER BLVD # 139
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-2043
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4364 WESTERN CENTER BLVD # 139
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-2043
Country	:	US
Telephone Number	:	636-448-4449
Fax Number	:

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

Provider Enumeration Date	:	04/30/2020
Last Update Date	:	04/30/2020

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