Healthcare Provider Details

I. General information

NPI: 1871126599
Provider Name (Legal Business Name): CLINICA NUEVO LEON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2020
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 TOM GILL RD
PENITAS TX
78576-7352
US

IV. Provider business mailing address

3601 TOM GILL RD
PENITAS TX
78576-7352
US

V. Phone/Fax

Practice location:
  • Phone: 956-778-4598
  • Fax:
Mailing address:
  • Phone: 956-778-4598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MIGUEL A MATA
Title or Position: FAMILY NURSE PRACTITIONER/PROVIDER
Credential: FNP-C
Phone: 956-778-4598