Provider Demographics
NPI:1962180661
Name:VILLARREAL, JESUS MANUEL
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:MANUEL
Last Name:VILLARREAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DANIEL
Other - Middle Name:
Other - Last Name:BUSTILLOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:401 PRIME DESERT DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79932-2146
Mailing Address - Country:US
Mailing Address - Phone:915-329-9131
Mailing Address - Fax:
Practice Address - Street 1:10105 WOLVERINE DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79924-4311
Practice Address - Country:US
Practice Address - Phone:915-329-9131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility