Healthcare Provider Details

I. General information

NPI: 1972074102
Provider Name (Legal Business Name): ALEXANDER LOUIS NESTOR IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 12/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 3RD ST W
RANDOLPH AFB TX
78150-4800
US

IV. Provider business mailing address

677 CREEKSIDE WAY APT 125
NEW BRAUNFELS TX
78130-5578
US

V. Phone/Fax

Practice location:
  • Phone: 210-652-2117
  • Fax:
Mailing address:
  • Phone: 920-883-5864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: