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General NPI Number Information
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NPI Number | 1487900718
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Entity Type | Organization
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Legal Business Name | RENUEVATE PA
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Dates
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Enumeration Date | 07/24/2012
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Last Update Date | 02/14/2014
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Provider Practice Location Address
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Address Line | 119 RETAMA STREET SUITE C
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City | ELSA
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State | TX
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Zip | 78543
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Country | US
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Telephone | 956-567-2236
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Fax | 956-567-2013
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Provider Business Mailing Address
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Address Line | 119 RETAMA STREET SUITE C
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City | ELSA
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State | TX
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Zip | 78543
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Country | US
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Telephone | 956-567-2236
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Fax | 956-567-2013
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Authorized Official
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Title or Position | CEO
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Name | DR. EDUARDO CARRILLO
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Credential | M.D.
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Telephone | 956-567-2236
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | L2172
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License Number State | TX
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