=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609821453
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRUDENICO AVENDANIO MDPA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2006
-----------------------------------------------------
Last Update Date | 04/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 719 W COKE RD
-----------------------------------------------------
City | WINNSBORO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75494-3011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-342-5227
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 8337
-----------------------------------------------------
City | AMARILLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79114-8337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-355-6593
-----------------------------------------------------
Fax | 806-352-8774
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. PRUDENCIO C AVENDANIO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 903-342-0921
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number | F4745
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085U0001X
-----------------------------------------------------
Taxonomy Name | Diagnostic Ultrasound Physician
-----------------------------------------------------
License Number | F4745
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | F4745
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------