Healthcare Provider Details

I. General information

NPI: 1528361649
Provider Name (Legal Business Name): MI ILUSION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2010
Last Update Date: 07/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3421 W PALMA VISTA DR
PALMVIEW TX
78572-1863
US

IV. Provider business mailing address

3421 W PALMA VISTA DR
PALMVIEW TX
78572-1863
US

V. Phone/Fax

Practice location:
  • Phone: 956-424-6067
  • Fax: 956-424-6166
Mailing address:
  • Phone: 956-424-6067
  • Fax: 956-424-6166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateTX

VIII. Authorized Official

Name: MS. CARMEN E RODRIGUEZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 956-457-1998