=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215384607
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FALFURRIAS FAMILY CLINIC, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2016
-----------------------------------------------------
Last Update Date | 05/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1204 S SAINT MARYS ST
-----------------------------------------------------
City | FALFURRIAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78355-5033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-323-2110
-----------------------------------------------------
Fax | 361-323-2118
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1204 S SAINT MARYS ST
-----------------------------------------------------
City | FALFURRIAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78355-5033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-323-2110
-----------------------------------------------------
Fax | 361-323-2118
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER
-----------------------------------------------------
Name | MARIO LUIS VASQUEZ AGUILAR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 917-733-2815
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | N7368
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------