=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053898734
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIO CAMPOS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2018
-----------------------------------------------------
Last Update Date | 07/25/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 409 N BRYAN RD STE 106
-----------------------------------------------------
City | MISSION
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78572-6293
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-600-7137
-----------------------------------------------------
Fax | 956-600-7139
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 409 N BRYAN RD STE 106
-----------------------------------------------------
City | MISSION
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78572-6293
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-600-7137
-----------------------------------------------------
Fax | 956-600-7139
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 34638
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------