1306462023 NPI number — SANTA A ROSADO DC

Table of content: SANTA A ROSADO DC (NPI 1306462023)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306462023 NPI number — SANTA A ROSADO DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSADO
Provider First Name:
SANTA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROSADO ACEVEDO
Provider Other First Name:
SANTA
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1306462023
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5577 CYPRESS WILLOW BND
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76126-2635
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-739-4682
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
912 W RANDOL MILL RD STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76012-2564
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
682-367-2219
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/18/2020

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: 111NI0013X , with the licence number:  14389 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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