=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245444744
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAPITAL NEUROSURGICAL ASSOCIATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2007
-----------------------------------------------------
Last Update Date | 02/24/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 711 WEST 38TH ST STE D-4
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-454-9627
-----------------------------------------------------
Fax | 512-454-6310
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 711 WEST 38TH ST STE D-4
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-454-9627
-----------------------------------------------------
Fax | 512-454-6310
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MR. RUEBEN RIVERA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 512-454-9627
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207T00000X
-----------------------------------------------------
Taxonomy Name | Neurological Surgery Physician
-----------------------------------------------------
License Number | D0073
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------