=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124586862
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDESSA INTEGRATIVE MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2019
-----------------------------------------------------
Last Update Date | 03/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4311 ANDREW HWY B
-----------------------------------------------------
City | MIDLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79703-4823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-935-7916
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4311 ANDREWS HWY # B
-----------------------------------------------------
City | MIDLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79703-4823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-935-7916
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MICHAEL JOSEPH PEREZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 877-935-7916
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------