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General NPI Number Information
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NPI Number | 1518580414
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Entity Type | Individual
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Provider Name | JERRY TYRONE LEMELLE CTRS
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Gender | Male
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Dates
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Enumeration Date | 05/26/2020
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Last Update Date | 05/26/2020
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Provider Practice Location Address
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Address Line | 4455 HORIZON HILL BLVD
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City | SAN ANTONIO
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State | TX
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Zip | 78229-2258
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Country | US
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Telephone | 337-794-8715
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Fax |
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Provider Business Mailing Address
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Address Line | 7400 MERTON MINTER ST
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City | SAN ANTONIO
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State | TX
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Zip | 78229-4404
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Country | US
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Telephone | 877-469-5300
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225800000X
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Taxonomy Name | Recreation Therapist
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License Number | 26454
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License Number State |
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