Healthcare Provider Details

I. General information

NPI: 1043560907
Provider Name (Legal Business Name): RICARDO CISNEROS CPHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: RICHARD CISNEROS

II. Dates (important events)

Enumeration Date: 09/18/2012
Last Update Date: 06/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2748 WORTH RD
FORT SAM HOUSTON TX
78234-6031
US

IV. Provider business mailing address

11519 LINGO
HELOTES TX
78023
US

V. Phone/Fax

Practice location:
  • Phone: 210-221-6428
  • Fax:
Mailing address:
  • Phone: 915-433-0765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number242092
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number500107010057077
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: