MEDICARE: CELSO RAUL ESPINOSA OWNER

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	171W00000X	Contractor

General Provider Information

NPI Number	:	1073096327
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CELSO RAUL ESPINOSA OWNER

Provider Business Mailing Address
First Line	:	314 E NAKOMA ST # W2
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-2794
Country	:	US
Telephone Number	:	210-404-4325
Fax Number	:

Provider Business Practice Location Address
First Line	:	314 E NAKOMA ST # W2
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-2794
Country	:	US
Telephone Number	:	210-404-4325
Fax Number	:	210-429-8160

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2018
Last Update Date	:	09/12/2018

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