Healthcare Provider Details

I. General information

NPI: 1114127867
Provider Name (Legal Business Name): RAUL MAURICIO LLANOS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2007
Last Update Date: 04/27/2020
Certification Date: 04/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2535 IRA E WOODS AVE
GRAPEVINE TX
76051-3930
US

IV. Provider business mailing address

2535 IRA E WOODS AVE
GRAPEVINE TX
76051-3930
US

V. Phone/Fax

Practice location:
  • Phone: 817-481-2121
  • Fax: 817-488-4493
Mailing address:
  • Phone: 817-481-2121
  • Fax: 817-488-4493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberN5816
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: