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General NPI Number Information
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NPI Number | 1083961403
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Entity Type | Organization
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Legal Business Name | RIO GRANDE STATE CENTER
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Dates
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Enumeration Date | 08/06/2012
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Last Update Date | 08/06/2012
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Provider Practice Location Address
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Address Line | 1401 S RANGERVILLE RD
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City | HARLINGEN
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State | TX
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Zip | 78552-7638
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Country | US
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Telephone | 956-364-8375
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Fax |
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Provider Business Mailing Address
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Address Line | 1401 S RANGERVILLE RD
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City | HARLINGEN
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State | TX
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Zip | 78552-7638
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Country | US
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Telephone | 956-364-8375
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Fax |
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | DR. DAVID MORON
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Credential | MD
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Telephone | 956-364-8375
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | DT82349
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License Number State | TX
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