Basic Information
| Provider Information | |||||||||
| NPI: | 1578933479 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUTIERREZ | ||||||||
| FirstName: | RUBEN | ||||||||
| MiddleName: | MARK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4928 COUNTRY FOREST LN | ||||||||
| Address2: | |||||||||
| City: | FRISCO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750343933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2543154655 | ||||||||
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| Practice Location | |||||||||
| Address1: | 915 W EXCHANGE PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ALLEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750137017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2145471571 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2015 | ||||||||
| LastUpdateDate: | 10/05/2015 | ||||||||
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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 | 225200000X | 2105529 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.