=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932309010
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KANTUTA, L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2007
-----------------------------------------------------
Last Update Date | 07/18/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14441 MEMORIAL DR SUITE 25
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77079-6744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-777-6677
-----------------------------------------------------
Fax | 713-621-9856
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14441 MEMORIAL DR SUITE 25
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77079-6744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-777-6677
-----------------------------------------------------
Fax | 713-621-9856
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DR.
-----------------------------------------------------
Name | ALEJANDRO XAVIER RIVERA
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 713-777-6677
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 8976
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------