Healthcare Provider Details

I. General information

NPI: 1659732220
Provider Name (Legal Business Name): ROLANDO SALAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2016
Last Update Date: 03/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 STEWART STREET
STINNETT TX
79083-7301
US

IV. Provider business mailing address

801 WILLIAMS STREET P.O. BOX 316
STINNETT TX
79083-7301
US

V. Phone/Fax

Practice location:
  • Phone: 806-878-2456
  • Fax: 806-878-4242
Mailing address:
  • Phone: 806-231-7243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number6430
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: