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General NPI Number Information
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NPI Number | 1619167921
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Entity Type | Organization
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Legal Business Name | SA-LTP PA
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Dates
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Enumeration Date | 08/01/2007
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Last Update Date | 09/25/2012
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Provider Practice Location Address
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Address Line | 20306 ENCINO LEDGE SUITE 101
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City | SAN ANTONIO
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State | TX
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Zip | 78259
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Country | US
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Telephone | 210-402-0138
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Fax | 210-402-0051
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Provider Business Mailing Address
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Address Line | 20306 ENCINO LEDGE SUITE 101
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City | SAN ANTONIO
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State | TX
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Zip | 78259
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Country | US
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Telephone | 210-402-0138
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Fax | 210-402-0051
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Authorized Official
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Title or Position | MANAGER
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Name | TERESA M ROCHABRUN
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Credential |
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Telephone | 210-402-0138
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | K3632
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License Number State | TX
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