MEDICARE: MR. SALVADOR R HERNANDEZ JR.

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	246RP1900X	Phlebotomy Technician	20221898066	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	92-0363466	OTHER	CO	MOBILE LAB SERVICE

General Provider Information

NPI Number	:	1275240343
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SALVADOR R HERNANDEZ JR.

Provider Business Mailing Address
First Line	:	5802 PIONEER MESA DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80923-8804
Country	:	US
Telephone Number	:	956-310-2967
Fax Number	:

Provider Business Practice Location Address
First Line	:	5802 PIONEER MESA DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80923-8804
Country	:	US
Telephone Number	:	956-310-2967
Fax Number	:

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

Provider Enumeration Date	:	10/28/2022
Last Update Date	:	10/28/2022

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