=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174861249
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HERNANDEZ ENTERPRISES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2013
-----------------------------------------------------
Last Update Date | 01/24/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 S SANTA FE AVE SUITE 102
-----------------------------------------------------
City | SALINA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67401-3980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 785-404-6065
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 215 S SANTA FE AVE SUITE 102
-----------------------------------------------------
City | SALINA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67401-3980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CLINICIAN
-----------------------------------------------------
Name | MS. TERESA E HERNANDEZ
-----------------------------------------------------
Credential | LSCSW
-----------------------------------------------------
Telephone | 785-404-6065
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LSCSW 4164
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------