Provider Demographics
NPI:1730731688
Name:BEBD TELEHEALTH
Entity type:Organization
Organization Name:BEBD TELEHEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-437-3077
Mailing Address - Street 1:2009 TREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-3959
Mailing Address - Country:US
Mailing Address - Phone:817-437-3077
Mailing Address - Fax:
Practice Address - Street 1:2009 TREMONT AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-3959
Practice Address - Country:US
Practice Address - Phone:817-437-3077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-11
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)Group - Single Specialty
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center