Healthcare Provider Details

I. General information

NPI: 1295216257
Provider Name (Legal Business Name): RICARDO LLANES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: RICHARD LLANES COTA

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 08/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1638 VZ CR 1803
GRAND SALINE TX
75140
US

IV. Provider business mailing address

1638 VZ COUNTY ROAD 1803
GRAND SALINE TX
75140-3494
US

V. Phone/Fax

Practice location:
  • Phone: 903-962-7595
  • Fax:
Mailing address:
  • Phone: 903-962-7595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number214308
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: