Basic Information
| Provider Information | |||||||||
| NPI: | 1679506190 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HIRACHETA | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5219 CITY BANK PKWY | ||||||||
| Address2: | STE 35 | ||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794073544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067857676 | ||||||||
| FaxNumber: | 8067857685 | ||||||||
| Practice Location | |||||||||
| Address1: | 2404 YONKERS ST | ||||||||
| Address2: | STE 11 | ||||||||
| City: | PLAINVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 790721820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8062962444 | ||||||||
| FaxNumber: | 8062969709 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 225X00000X | 109569 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.