MEDICARE: CANTU FAMILY MEDICAL CLINIC PROFESSIONAL LIMITED LIABILITY COMPANY

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	363LF0000X	Family Nurse Practitioner	AP122465	TX

General Provider Information

NPI Number	:	1245625201
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANTU FAMILY MEDICAL CLINIC PROFESSIONAL LIMITED LIABILITY COMPANY

Provider Business Mailing Address
First Line	:	PO BOX 2419
Second Line	:
City	:	SAN JUAN
State	:	TX
Zip	:	78589-7419
Country	:	US
Telephone Number	:	956-787-5303
Fax Number	:	956-787-8117

Provider Business Practice Location Address
First Line	:	409 W FM 495
Second Line	:
City	:	SAN JUAN
State	:	TX
Zip	:	78589-3717
Country	:	US
Telephone Number	:	956-787-5303
Fax Number	:	956-787-8117

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ROEL ESTEBAN CANTU SR.
Credential	:	MD
Telephone Number	:	956-787-8100

Provider Enumeration Date	:	04/06/2015
Last Update Date	:	04/04/2016

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