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NPI Code Detail

MEDICARE: ISSAC ROY BALLESTEROS 101Y00000X

MEDICARE: ISSAC ROY BALLESTEROS 101Y00000X
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101Y00000XCounselor99657TX

General Provider Information

NPI Number : 1134896863
Entity Type Code : Individual
Provider Name (Legal Business Name) : ISSAC ROY BALLESTEROS 101Y00000X
Provider Business Mailing Address
First Line : 4200 S HULEN ST STE 436
Second Line :
City : FORT WORTH
State : TX
Zip : 76109-4910
Country : US
Telephone Number : 817-952-8180
Fax Number :
Provider Business Practice Location Address
First Line : 4200 S HULEN ST STE 436
Second Line :
City : FORT WORTH
State : TX
Zip : 76109-4910
Country : US
Telephone Number : 817-952-8180
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/30/2021
Last Update Date : 12/04/2025

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