=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134685480
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONNOISSEUR HEALTH PROS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2019
-----------------------------------------------------
Last Update Date | 02/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1615 S. VETERANS BLVD.
-----------------------------------------------------
City | EAGLE PASS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78852
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-968-3050
-----------------------------------------------------
Fax | 866-571-0395
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1615 S. VETERANS BLVD.
-----------------------------------------------------
City | EAGLE PASS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78852
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-968-3050
-----------------------------------------------------
Fax | 866-571-0395
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. GERARDO DARIEL VILLALPANDO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 830-968-3050
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------