Most Relevant Information
Provider Data
| NPI Number: | 1003581455 |
| Provider Name: | ALEX KENNETH GOTTLEABER ATP |
| Entity Type: | Individual |
| Taxonomy Code: | 247200000X |
| Specialty: | Technician, Other |
| License Number: | 91528 |
Most Important Dates
| Enumeration Date: | 08/09/2021 |
| Last Updated: | 11/24/2021 |
Provider Practice Location
1101 W VICKERY BLVD
FORT WORTH
TX
761041025
Practice Location Phone/Fax
| Phone: | 6828856294 |
| Fax: | 6828851135 |
Provider Mailing Location
PO BOX 99283
FORT WORTH
TX
761991383
Provider Mailing Phone/Fax
| Phone: | 6828856294 |
| Fax: | 6828851135 |