MEDICARE: ITACHICO, PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	246ZE0600X	Electroneurodiagnostic Specialist/Technologist
2	204R00000X	Electrodiagnostic Medicine Physician
3	2084N0400X	Neurology Physician
4	2084N0600X	Clinical Neurophysiology Physician

General Provider Information

NPI Number	:	1417617986
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ITACHICO, PLLC

Provider Business Mailing Address
First Line	:	1141 N LOOP 1604 E # 105-612
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78232-1339
Country	:	US
Telephone Number	:	210-598-4277
Fax Number	:

Provider Business Practice Location Address
First Line	:	2214 HAMLET CIRCLE
Second Line	:
City	:	ROUND ROCK
State	:	TX
Zip	:	78664
Country	:	US
Telephone Number	:	210-598-4277
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF CLIENT EXPERIENCE
Name	:	ROXANNA LAROQUE
Credential	:
Telephone Number	:	210-598-4277

Provider Enumeration Date	:	12/27/2021
Last Update Date	:	10/03/2024

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