Provider Demographics
NPI:1386338127
Name:INFINIT MEN'S HEALTH CLINIC - FORT WORTH
Entity type:Organization
Organization Name:INFINIT MEN'S HEALTH CLINIC - FORT WORTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:MCKENZIE
Authorized Official - Last Name:KELLEHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-550-4924
Mailing Address - Street 1:3728 BENBROOK HWY
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-9429
Mailing Address - Country:US
Mailing Address - Phone:682-250-3362
Mailing Address - Fax:
Practice Address - Street 1:3728 BENBROOK HWY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-9429
Practice Address - Country:US
Practice Address - Phone:682-250-3362
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center