Provider Demographics
NPI:1588383632
Name:PALACIOS, MAXIMILIANO MEDINA
Entity type:Individual
Prefix:
First Name:MAXIMILIANO
Middle Name:MEDINA
Last Name:PALACIOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6920 HOMESTEAD AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-2957
Mailing Address - Country:US
Mailing Address - Phone:254-477-4085
Mailing Address - Fax:
Practice Address - Street 1:6920 HOMESTEAD AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-2957
Practice Address - Country:US
Practice Address - Phone:254-477-4085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer