MEDICARE: PEQUIN DME-A SALSA INGREDIENT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BX2000X	Oxygen Equipment & Supplies (DME)	0093615	TX

General Provider Information

NPI Number	:	1003055674
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEQUIN DME-A SALSA INGREDIENT

Provider Business Mailing Address
First Line	:	4865 FREDERICKSBURG RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3627
Country	:	US
Telephone Number	:	210-479-7704
Fax Number	:	210-479-2692

Provider Business Practice Location Address
First Line	:	1313 GUADALUPE ST
Second Line	:	STE 203
City	:	SAN ANTONIO
State	:	TX
Zip	:	78207-5546
Country	:	US
Telephone Number	:	210-479-7707
Fax Number	:	210-479-2692

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. CHRISTAL TORRENS
Credential	:
Telephone Number	:	210-479-7704

Provider Enumeration Date	:	02/05/2009
Last Update Date	:	07/17/2009

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