Healthcare Provider Details

I. General information

NPI: 1275942534
Provider Name (Legal Business Name): MATTHEW ESTRADA LVN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2014
Last Update Date: 08/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2602 SAN DIEGO
MISSION TX
78572-7186
US

IV. Provider business mailing address

2602 SAN DIEGO
MISSION TX
78572-7186
US

V. Phone/Fax

Practice location:
  • Phone: 956-329-9888
  • Fax:
Mailing address:
  • Phone: 956-329-9888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number214561
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: