=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740815091
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. LOUIS RAY KOMUREK
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2020
-----------------------------------------------------
Last Update Date | 03/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4335 W PIEDRAS DR STE 201
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78228-1209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-319-0091
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14526 SACRED
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78247-6605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-319-0091
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 76997
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------