Healthcare Provider Details

I. General information

NPI: 1689157679
Provider Name (Legal Business Name): MARITES KWAN CUPPS I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2018
Last Update Date: 09/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4205 PALMER DR
MANSFIELD TX
76063-3432
US

IV. Provider business mailing address

4205 PALMER DR
MANSFIELD TX
76063-3432
US

V. Phone/Fax

Practice location:
  • Phone: 817-657-1103
  • Fax:
Mailing address:
  • Phone: 817-657-1103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1085264
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: