Healthcare Provider Details

I. General information

NPI: 1336854710
Provider Name (Legal Business Name): CLINICA DE CABEZ Y CUELLO AMD CARE CHOPO DIAGNOSTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2023
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BUENOS AIRES 2779 #3 COL PROVIDENCIA
GUADALAJARA MEXICO
44630
MX

IV. Provider business mailing address

5830 E 2ND ST
CASPER WY
82609-4308
US

V. Phone/Fax

Practice location:
  • Phone: 888-449-7799
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAVIER EZQUERRA
Title or Position: MGR
Credential: DR
Phone: 888-449-7799