MEDICARE: BLACKLAND PRAIRIE MEDICAL PLLC

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	204D00000X	Neuromusculoskeletal Medicine & OMM Physician

General Provider Information

NPI Number	:	1902359821
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACKLAND PRAIRIE MEDICAL PLLC

Provider Business Mailing Address
First Line	:	9330 VALLEY GATE
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78250-5773
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9330 VALLEY GATE
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78250-5773
Country	:	US
Telephone Number	:	210-262-0328
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	EMMA RODRIGUEZ
Credential	:
Telephone Number	:	210-262-0328

Provider Enumeration Date	:	07/27/2016
Last Update Date	:	07/27/2016

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