Provider Demographics
NPI:1194894683
Name:ACOSTA, JUAN GUILLERMO (PT)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:GUILLERMO
Last Name:ACOSTA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4849 N MESA ST STE 201
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-5919
Mailing Address - Country:US
Mailing Address - Phone:915-351-6600
Mailing Address - Fax:915-351-6601
Practice Address - Street 1:11395 JAMES WATT DR STE A6
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-5941
Practice Address - Country:US
Practice Address - Phone:915-629-7669
Practice Address - Fax:915-629-7679
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1047876225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX299447YNCDMedicare PIN