Healthcare Provider Details

I. General information

NPI: 1124202064
Provider Name (Legal Business Name): RAQUEL CISNEROS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 12/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 AUGUSTA DR SUITE 183
HOUSTON TX
77057
US

IV. Provider business mailing address

2400 AUGUSTA DR SUITE 183
HOUSTON TX
77057
US

V. Phone/Fax

Practice location:
  • Phone: 713-553-1012
  • Fax:
Mailing address:
  • Phone: 713-553-1012
  • Fax: 713-975-7197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT019516
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: