Provider Demographics
NPI:1285377507
Name:MDOC HEALTH SERVICES,LLC
Entity type:Organization
Organization Name:MDOC HEALTH SERVICES,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ALIESKI
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTRAPA DOMINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-381-6190
Mailing Address - Street 1:PO BOX 2799
Mailing Address - Street 2:
Mailing Address - City:PORTER
Mailing Address - State:TX
Mailing Address - Zip Code:77365-2799
Mailing Address - Country:US
Mailing Address - Phone:281-381-6190
Mailing Address - Fax:281-747-7162
Practice Address - Street 1:4371 S 1ST ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79605-1469
Practice Address - Country:US
Practice Address - Phone:325-701-4082
Practice Address - Fax:325-701-4081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-14
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty