Healthcare Provider Details

I. General information

NPI: 1033282629
Provider Name (Legal Business Name): JUAN CARLOS DE LA CERDA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 08/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1902 50TH ST
LUBBOCK TX
79412-2706
US

IV. Provider business mailing address

PO BOX 54136
LUBBOCK TX
79453-4136
US

V. Phone/Fax

Practice location:
  • Phone: 806-771-1386
  • Fax: 806-771-1388
Mailing address:
  • Phone: 806-771-1386
  • Fax: 806-771-1388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number25718
License Number StateTX

VIII. Authorized Official

Name: JUAN CARLOS DE LE CERDA
Title or Position: OWNER
Credential: RVT, RVS, RDCS, RCS
Phone: 806-791-5930