Basic Information
| Provider Information | |||||||||
| NPI: | 1144411901 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TEXAS TECH UNIVERSITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 DE LEON DR | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799124543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155813830 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9849 KENWORTHY ST | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799244402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157573178 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2007 | ||||||||
| LastUpdateDate: | 08/07/2007 | ||||||||
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| AuthorizedOfficialLastName: | CARDENTEY | ||||||||
| AuthorizedOfficialFirstName: | LUIS | ||||||||
| AuthorizedOfficialMiddleName: | ALBERTO | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN IN TRAINING | ||||||||
| AuthorizedOfficialTelephone: | 9155813830 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | SR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 23410660985 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.