Healthcare Provider Details

I. General information

NPI: 1588486062
Provider Name (Legal Business Name): JOSE VAZQUEZ-AYALA BS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 TRIMMIER RD
KILLEEN TX
76542-2650
US

IV. Provider business mailing address

3800 TRIMMIER RD
KILLEEN TX
76542-2650
US

V. Phone/Fax

Practice location:
  • Phone: 254-317-5603
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-384867
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: