Healthcare Provider Details

I. General information

NPI: 1114395860
Provider Name (Legal Business Name): COLINASVERSE IOM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2015
Last Update Date: 09/11/2015
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: 817-885-7339
Mailing address:
  • Phone: 817-908-8124
  • Fax: 817-885-7339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State

VIII. Authorized Official

Name: DR. AUGUSTO CEZAR LASTIMOSA
Title or Position: MANAGING MEMBER
Credential: M.D.
Phone: 817-366-4777