Basic Information
Provider Information | |||||||||
NPI: | 1700943727 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GUTIERREZ | ||||||||
FirstName: | ALDOLFO | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PTA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GUTIERREZ | ||||||||
OtherFirstName: | ALDOLFO | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PTA | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 2805 FOUNTAIN PLAZA BLVD | ||||||||
Address2: |   | ||||||||
City: | EDINBURG | ||||||||
State: | TX | ||||||||
PostalCode: | 785398031 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9563162224 | ||||||||
FaxNumber: | 9563160445 | ||||||||
Practice Location | |||||||||
Address1: | 1403 N SEYMOUR AVE | ||||||||
Address2: |   | ||||||||
City: | LAREDO | ||||||||
State: | TX | ||||||||
PostalCode: | 780408752 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9567236700 | ||||||||
FaxNumber: | 9567245559 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/02/2007 | ||||||||
LastUpdateDate: | 03/10/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2048148 | TX | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 2048148 | 01 | TX | PTA | OTHER |