Healthcare Provider Details

I. General information

NPI: 1588484497
Provider Name (Legal Business Name): TARA CISCO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2024
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 SARATOGA BLVD UNIT 2
CORPUS CHRISTI TX
78414-3478
US

IV. Provider business mailing address

6222 W IH 10 STE 104
SAN ANTONIO TX
78201-2013
US

V. Phone/Fax

Practice location:
  • Phone: 361-717-1608
  • Fax:
Mailing address:
  • Phone: 210-447-0039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: