=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942675962
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RGV PREMIER HEALTH SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2015
-----------------------------------------------------
Last Update Date | 07/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4413 W BUSINESS 83 SUITE 8
-----------------------------------------------------
City | MCALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78501-8607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-605-4413
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4413 W BUSINESS 83 SUITE 8
-----------------------------------------------------
City | MCALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78501-8607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OCCUPATIONAL THERAPIST
-----------------------------------------------------
Name | MR. NOE BAZAN
-----------------------------------------------------
Credential | OTR
-----------------------------------------------------
Telephone | 956-605-4413
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 114651
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------