=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407074305
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUAN MANUEL MARROQUIN OPTICIAN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4416 PAREDES LINE RD
-----------------------------------------------------
City | BROWNSVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78526-1114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-986-2995
-----------------------------------------------------
Fax | 956-986-2996
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4416 PAREDES LINE RD
-----------------------------------------------------
City | BROWNSVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78526-1114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-986-2995
-----------------------------------------------------
Fax | 956-986-2996
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | 43539
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------