Healthcare Provider Details

I. General information

NPI: 1437925732
Provider Name (Legal Business Name): SAN JUAN PRIMARY HOME CARE AGENCY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2023
Last Update Date: 05/31/2024
Certification Date: 05/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 MOURSUND BOULEVARD
SAN ANTONIO TX
78221
US

IV. Provider business mailing address

545 MOURSUND BLVD
SAN ANTONIO TX
78221-3938
US

V. Phone/Fax

Practice location:
  • Phone: 210-927-7712
  • Fax: 210-927-7713
Mailing address:
  • Phone: 210-927-7712
  • Fax: 210-927-7713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. AUGUSTIN ESTRADA III
Title or Position: ADMINISTRATOR
Credential:
Phone: 210-927-7712