MEDICARE: ALEXANDRIA CONCEPCION CANTU RD, LD

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
1	133V00000X	Registered Dietitian	DT86290	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	86119534	OTHER	TX	REGISTRATION ID NUMBER
2	DT86290	OTHER	TX	LICENSED DIETITIAN

General Provider Information

NPI Number	:	1578100616
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXANDRIA CONCEPCION CANTU RD, LD

Provider Business Mailing Address
First Line	:	9542 CANTURA CRST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78250-1719
Country	:	US
Telephone Number	:	210-387-3383
Fax Number	:

Provider Business Practice Location Address
First Line	:	9542 CANTURA CRST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78250-1719
Country	:	US
Telephone Number	:	210-387-3383
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/09/2019
Last Update Date	:	12/09/2019

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