=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629795406
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAUL JAMES PRIETO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2022
-----------------------------------------------------
Last Update Date | 10/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 112 HERFF RD STE 310
-----------------------------------------------------
City | BOERNE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78006-2750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-431-9660
-----------------------------------------------------
Fax | 830-431-9661
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7505 N LOOP 1604 E STE 101
-----------------------------------------------------
City | LIVE OAK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78233-2799
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-590-4000
-----------------------------------------------------
Fax | 210-590-4585
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------