=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235539750
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DFAS-JFLL/IN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2014
-----------------------------------------------------
Last Update Date | 09/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4005 RAYNOR PKWY APT 3316
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68123-6110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-862-0632
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4005 RAYNOR PKWY APT 3316
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68123-6110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-862-0632
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN ASSISTANT
-----------------------------------------------------
Name | MARINA PUENTES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 210-862-0632
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------