Basic Information
| Provider Information | |||||||||
| NPI: | 1740891936 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF TEXAS RIO GRANDE VALLEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2102 TREASURE HILLS BLVD # 3.14406 | ||||||||
| Address2: | |||||||||
| City: | HARLINGEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785508736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9562961437 | ||||||||
| FaxNumber: | 9562966842 | ||||||||
| Practice Location | |||||||||
| Address1: | 1214 W SCHUNIOR ST BLDG 2.318 | ||||||||
| Address2: | |||||||||
| City: | EDINBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785412337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9562961731 | ||||||||
| FaxNumber: | 9562961730 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2020 | ||||||||
| LastUpdateDate: | 08/12/2020 | ||||||||
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| AuthorizedOfficialLastName: | KROUSE | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | HOBART | ||||||||
| AuthorizedOfficialTitleorPosition: | EXEC. VICE PRESIDENT, HEALTH AFFAIR | ||||||||
| AuthorizedOfficialTelephone: | 9562961445 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 45D2181340 | 01 | TX | CLIA | OTHER |