Basic Information
| Provider Information | |||||||||
| NPI: | 1194852418 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MISSION CARDIOVASCULAR CONSULTANTS | ||||||||
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| OtherOrganizationName: | NEW BRAUNFELS CARDIOLOGY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 949 | ||||||||
| Address2: | |||||||||
| City: | LA GRANGE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 789450949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8306201272 | ||||||||
| FaxNumber: | 8306201274 | ||||||||
| Practice Location | |||||||||
| Address1: | 1626 COMMON ST | ||||||||
| Address2: | |||||||||
| City: | NEW BRAUNFELS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 781303156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8306201272 | ||||||||
| FaxNumber: | 8306201274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 09/11/2017 | ||||||||
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| AuthorizedOfficialLastName: | BETTS | ||||||||
| AuthorizedOfficialFirstName: | DARLA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE ADMINSTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8306201272 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | Q1864 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 079747402 | 05 | TX | MEDICAID |