=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538801923
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMD FREEDOM ENTERPRISES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2022
-----------------------------------------------------
Last Update Date | 08/31/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 TRULY PLZ
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77327-4889
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-480-5313
-----------------------------------------------------
Fax | 832-480-5314
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2799
-----------------------------------------------------
City | PORTER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77365-2799
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-381-6190
-----------------------------------------------------
Fax | 281-747-7162
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | ALIESKI MASTRAPA DOMINGUEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 281-381-6190
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------