=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487790176
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIABETES RELATED EDUCATION & MGMT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1576 LOMALAND DR STE B-1
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79935-4202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-772-2007
-----------------------------------------------------
Fax | 915-772-2407
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1576 LOMALAND DR STE B-1
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79935-4202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-772-2007
-----------------------------------------------------
Fax | 915-772-2407
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. EUSTACIO RIVAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 915-772-2007
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------