Healthcare Provider Details

I. General information

NPI: 1689075095
Provider Name (Legal Business Name): TXIOM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2014
Last Update Date: 09/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 THROCKMORTON STREET UNIT 3012
FORT WORTH TX
76102
US

IV. Provider business mailing address

500 THROCKMORTON STREET UNIT 3012
FORT WORTH TX
76102
US

V. Phone/Fax

Practice location:
  • Phone: 817-908-8124
  • Fax:
Mailing address:
  • Phone: 817-908-8124
  • Fax: 817-885-7339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberF0555
License Number StateTX

VIII. Authorized Official

Name: DR. AUGUSTO CEZAR LASTIMOSA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 817-908-8124