MEDICARE: MBSSA

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	251V00000X	Voluntary or Charitable Agency

General Provider Information

NPI Number	:	1043554165
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MBSSA

Provider Business Mailing Address
First Line	:	2714 THUNDER GULCH
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78245
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2714 THUNDER GULCH
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78245
Country	:	US
Telephone Number	:	210-430-1089
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR/FOUNDER
Name	:	DR. MICHELLE NUNN
Credential	:	PH.D
Telephone Number	:	210-430-1089

Provider Enumeration Date	:	11/15/2012
Last Update Date	:	11/15/2012

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