=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316394885
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIRST LINE SUPPORT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2016
-----------------------------------------------------
Last Update Date | 05/15/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8463 E HWY 107 SUITE E
-----------------------------------------------------
City | EDINBURG
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78542-1704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-252-0777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3705 SYCAMORE DR
-----------------------------------------------------
City | EDINBURG
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78542-2420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-533-4079
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | BERTHA ALICIA TAMEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 956-533-4079
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------