Basic Information
| Provider Information | |||||||||
| NPI: | 1477997252 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARRASCO | ||||||||
| FirstName: | MARIO | ||||||||
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| NameSuffix: | JR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1541 E 51ST ST | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797624440 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1200 W 15TH ST | ||||||||
| Address2: | |||||||||
| City: | MONAHANS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797568301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888734221 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2013 | ||||||||
| LastUpdateDate: | 04/23/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2067933 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.