Provider Demographics
NPI:1588155451
Name:ACOSTA, JUAN DANIEL (PT)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:DANIEL
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 1:1501 CIMARRON RDG
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-8141
Mailing Address - Country:US
Mailing Address - Phone:915-850-4401
Mailing Address - Fax:915-832-0865
Practice Address - Street 1:7430 REMCON CIR BLDG A
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912
Practice Address - Country:US
Practice Address - Phone:915-231-2285
Practice Address - Fax:915-231-2288
Is Sole Proprietor?:No
Enumeration Date:2018-05-25
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3122281225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist