Provider Demographics
NPI:1376053215
Name:FORT WORTH HEALTH ALLIANCE, LLC
Entity Type:Organization
Organization Name:FORT WORTH HEALTH ALLIANCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:GIDEON
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAWEEK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:817-498-7333
Mailing Address - Street 1:3625 WESTERN CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-1936
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3625 WESTERN CENTER BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-1936
Practice Address - Country:US
Practice Address - Phone:817-498-7333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-05
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty