Healthcare Provider Details

I. General information

NPI: 1922681022
Provider Name (Legal Business Name): MELISA CARRASCO CCM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2021
Last Update Date: 05/05/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 SCHOFIELD RD BLDG 1179
FORT SAM HOUSTON TX
78234-7577
US

IV. Provider business mailing address

9102 SPIGEL WAY
CONVERSE TX
78109-0210
US

V. Phone/Fax

Practice location:
  • Phone: 210-808-6524
  • Fax: 210-539-2075
Mailing address:
  • Phone: 210-808-6524
  • Fax: 210-539-2084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number504829
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: