MEDICARE: CARLOS IVAN QUINTANA LVN

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	164X00000X	Licensed Vocational Nurse	342775	TX

General Provider Information

NPI Number	:	1679112114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLOS IVAN QUINTANA LVN

Provider Business Mailing Address
First Line	:	12949 EASTBROOK DR APT 353
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79938-5537
Country	:	US
Telephone Number	:	714-269-5241
Fax Number	:

Provider Business Practice Location Address
First Line	:	12949 EASTBROOK DR APT 353
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79938-5537
Country	:	US
Telephone Number	:	714-269-5241
Fax Number	:

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

Provider Enumeration Date	:	01/02/2020
Last Update Date	:	01/02/2020

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