Healthcare Provider Details

I. General information

NPI: 1689225617
Provider Name (Legal Business Name): JUAN JOSE ZAVALA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3765 S ALAMEDA ST STE 251
CORPUS CHRISTI TX
78411-1655
US

IV. Provider business mailing address

6534 MACARENA DR
CORPUS CHRISTI TX
78414-6447
US

V. Phone/Fax

Practice location:
  • Phone: 361-937-7887
  • Fax:
Mailing address:
  • Phone: 210-429-2555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number929097
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: