Healthcare Provider Details

I. General information

NPI: 1134957830
Provider Name (Legal Business Name): OMAFF HURTADO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2024
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 6631 BOX 1420
DPO AE
09310-9997
US

IV. Provider business mailing address

7442 OAK MARSH ST
LIVE OAK TX
78233-3113
US

V. Phone/Fax

Practice location:
  • Phone: 210-990-7046
  • Fax:
Mailing address:
  • Phone: 210-990-7046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number64730
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number93192
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: