1164419156 NPI number — MARISSA J VILLARREAL PA

Table of content: MRS. RENITA OSBORN PMHNP (NPI 1013298694)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164419156 NPI number — MARISSA J VILLARREAL PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VILLARREAL
Provider First Name:
MARISSA
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164419156
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/09/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
204 E 1ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALICE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78332-4822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
361-664-0145
Provider Business Mailing Address Fax Number:
361-664-2248

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 S HILLSIDE DR
Provider Second Line Business Practice Location Address:
SUITES 5,6,15
Provider Business Practice Location Address City Name:
BEEVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78102-5307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-362-0307
Provider Business Practice Location Address Fax Number:
361-362-0221
Provider Enumeration Date:
10/04/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  C03187 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 201815201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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