Healthcare Provider Details

I. General information

NPI: 1982184065
Provider Name (Legal Business Name): ILEANA JUAREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2018
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 TOURNAMENT TRAIL DR
LAREDO TX
78041-6564
US

IV. Provider business mailing address

131 PACIFICO DR
LAREDO TX
78045-6816
US

V. Phone/Fax

Practice location:
  • Phone: 956-727-3422
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1221761
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: