Basic Information
Provider Information | |||||||||
NPI: | 1679054936 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TREJO VARGAS | ||||||||
FirstName: | JOSE | ||||||||
MiddleName: | ROBERTO | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PTA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 500 LINDBERG AVE | ||||||||
Address2: |   | ||||||||
City: | MCALLEN | ||||||||
State: | TX | ||||||||
PostalCode: | 785012924 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9566874560 | ||||||||
FaxNumber: | 9566874554 | ||||||||
Practice Location | |||||||||
Address1: | 1317 ST CLAIRE BLVD STE A | ||||||||
Address2: |   | ||||||||
City: | MISSION | ||||||||
State: | TX | ||||||||
PostalCode: | 785726636 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9565843535 | ||||||||
FaxNumber: | 9565843633 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/24/2018 | ||||||||
LastUpdateDate: | 08/24/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2131070 | TX | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 2131070 | 01 | TX | ECTOPE | OTHER |