=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720630759
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CIGARROA INTERVENTIONAL -ASC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2019
-----------------------------------------------------
Last Update Date | 12/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7105 N BARTLETT AVE
-----------------------------------------------------
City | LAREDO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78041-6465
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-234-2609
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7105 N BARTLETT AVE
-----------------------------------------------------
City | LAREDO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78041-6465
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | CESAR RODRIGUEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 956-235-2609
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------