MEDICARE: ACE SURGICAL ASSISTANT

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	363AS0400X	Surgical Physician Assistant	SA00643	TX

General Provider Information

NPI Number	:	1871070151
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACE SURGICAL ASSISTANT

Provider Business Mailing Address
First Line	:	3227 MULBERRY HILL LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77084-5525
Country	:	US
Telephone Number	:	832-800-6798
Fax Number	:

Provider Business Practice Location Address
First Line	:	3227 MULBERRY HILL LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77084-5525
Country	:	US
Telephone Number	:	832-800-6798
Fax Number	:

Authorized Official
Title or Position	:	SURGICAL ASSISTANT
Name	:	MR. MARIO ARNOLDO RIVAS
Credential	:	LSA
Telephone Number	:	832-800-6798

Provider Enumeration Date	:	07/19/2018
Last Update Date	:	08/17/2018

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