Provider Demographics
NPI:1194138420
Name:RIOS, MARY JESUSA
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JESUSA
Last Name:RIOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7043 BANDERA RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78238-1266
Mailing Address - Country:US
Mailing Address - Phone:210-384-9201
Mailing Address - Fax:210-384-9212
Practice Address - Street 1:7043 BANDERA RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78238-1266
Practice Address - Country:US
Practice Address - Phone:210-384-9201
Practice Address - Fax:210-384-9212
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-04
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100551332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX100551OtherLICENSE