=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760463715
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. JOYCE EVET SQUIRES
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2005
-----------------------------------------------------
Last Update Date | 10/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7400 MERTON MINTER ST # 11P
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78229-4404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-617-5300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 170 OUTER LOOP ROAD USAMEDDAC KAHC ATTN: CREDENTIALS OFFICE
-----------------------------------------------------
City | FORT IRWIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-380-2780
-----------------------------------------------------
Fax | 760-380-7101
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number | 612303
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------