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NPI Code Detail

MEDICARE: PETRA HEALTH, INC.

MEDICARE: PETRA HEALTH, INC.
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
1251E00000XHome Health Agency013766TX

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1013766OTHERTXHOME HEALTH LICENSE

General Provider Information

NPI Number : 1629056577
Entity Type Code : Organization
Provider Name (Legal Business Name) : PETRA HEALTH, INC.
Provider Business Mailing Address
First Line : 10010 SAN PEDRO AVE
Second Line : STE 120
City : SAN ANTONIO
State : TX
Zip : 78216-3862
Country : US
Telephone Number : 210-495-5493
Fax Number : 210-491-4331
Provider Business Practice Location Address
First Line : 10010 SAN PEDRO AVE
Second Line : STE 120
City : SAN ANTONIO
State : TX
Zip : 78216-3862
Country : US
Telephone Number : 210-495-5493
Fax Number : 210-491-4331
Authorized Official
Title or Position : DIRECTOR
Name : AMIR MORTAZAVI
Credential :
Telephone Number : 210-495-5493
Provider Enumeration Date : 01/02/2006
Last Update Date : 12/17/2012

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