| NPI | 1114289956 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MAURO PROVENCIO Md/Owner 915-525-3209 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: TX P1809) |
| Enumeration Date | 2012-06-07 |
| Last Update Date | 2024-06-18 |