Healthcare Provider Details

I. General information

NPI: 1285377507
Provider Name (Legal Business Name): MDOC HEALTH SERVICES,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2022
Last Update Date: 04/15/2022
Certification Date: 04/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4371 S 1ST ST
ABILENE TX
79605-1469
US

IV. Provider business mailing address

PO BOX 2799
PORTER TX
77365-2799
US

V. Phone/Fax

Practice location:
  • Phone: 325-701-4082
  • Fax: 325-701-4081
Mailing address:
  • Phone: 281-381-6190
  • Fax: 281-747-7162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ALIESKI MASTRAPA DOMINGUEZ
Title or Position: MEMBER
Credential:
Phone: 281-381-6190