1427384981 NPI number — PEDRO MEDRANO

Table of content: (NPI 1427384981)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427384981 NPI number — PEDRO MEDRANO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDRO MEDRANO
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427384981
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
909 IVY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DONNA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78537-3978
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-355-1413
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 N VERMONT AVE
Provider Second Line Business Practice Location Address:
SUITE #A
Provider Business Practice Location Address City Name:
MERCEDES
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78570-2519
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-565-9438
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/19/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MEDRANO
Authorized Official First Name:
PEDRO
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/ ADDMINISTRATOR
Authorized Official Telephone Number:
956-565-9438

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  11420096429 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 281518502 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 281518501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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