Basic Information
| Provider Information | |||||||||
| NPI: | 1336509868 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUAJARDO | ||||||||
| FirstName: | ALEJANDRO | ||||||||
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| Credential: | C.O.T.A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 NE LOOP 820 | ||||||||
| Address2: | ; BUSINESS TOWER 1, SUITE 200; HURST, TX 76053 | ||||||||
| City: | HURST | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760537209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172928787 | ||||||||
| FaxNumber: | 8177896849 | ||||||||
| Practice Location | |||||||||
| Address1: | 1505 CALLE DEL NORTE | ||||||||
| Address2: | #440 | ||||||||
| City: | LAREDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780416036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9567226221 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2016 | ||||||||
| LastUpdateDate: | 02/25/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 213790 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.