=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346765542
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE WENTWORTH INSTITUTE OF PLASTIC AND RECONSTRUCTIVE SURGERY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2017
-----------------------------------------------------
Last Update Date | 01/05/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 N ED CAREY DR
-----------------------------------------------------
City | HARLINGEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78550-7919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-300-5022
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 801 N ED CAREY DR
-----------------------------------------------------
City | HARLINGEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78550-7919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MONICA P WENTWORTH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 210-392-4971
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------