Healthcare Provider Details

I. General information

NPI: 1861976706
Provider Name (Legal Business Name): RAYMOND RAMIREZ PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2018
Last Update Date: 09/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 CHARLOTTE ST
SAN BENITO TX
78586-3422
US

IV. Provider business mailing address

411 CHARLOTTE ST
SAN BENITO TX
78586-3422
US

V. Phone/Fax

Practice location:
  • Phone: 256-640-1402
  • Fax:
Mailing address:
  • Phone: 256-640-1402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2139971
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: