Healthcare Provider Details

I. General information

NPI: 1639619380
Provider Name (Legal Business Name): SA CHILD NEUROLOGICAL ASSOCIATION, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2017
Last Update Date: 05/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7254 BLANCO RD STE 104
SAN ANTONIO TX
78216-4930
US

IV. Provider business mailing address

7254 BLANCO RD STE 104
SAN ANTONIO TX
78216-4930
US

V. Phone/Fax

Practice location:
  • Phone: 210-816-3837
  • Fax:
Mailing address:
  • Phone: 210-816-3837
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberJ7741
License Number StateTX

VIII. Authorized Official

Name: JOSE L ACEVES
Title or Position: PRESIDENT
Credential: M.D.
Phone: 210-816-3837