Basic Information
| Provider Information | |||||||||
| NPI: | 1447975016 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AQUINO MEDINA | ||||||||
| FirstName: | EBEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | DC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 700688 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782700688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103183007 | ||||||||
| FaxNumber: | 2104680682 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 MEDICAL CENTER PKWY STE 300 | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773404959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004046050 | ||||||||
| FaxNumber: | 8663133397 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2022 | ||||||||
| LastUpdateDate: | 10/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111NR0400X | 15247 | TX | Y | Chiropractic Providers | Chiropractor | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 15247 | 01 | TX | TX CHIROPRACTIC LICENSE | OTHER |