Provider Demographics
NPI:1003507831
Name:CORDERO, REUBEN
Entity Type:Individual
Prefix:
First Name:REUBEN
Middle Name:
Last Name:CORDERO
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 1:4821 LOVELL AVE
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-5326
Mailing Address - Country:US
Mailing Address - Phone:682-556-9487
Mailing Address - Fax:
Practice Address - Street 1:6201 SUNSET DR STE 121
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-5535
Practice Address - Country:US
Practice Address - Phone:682-556-9487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT123617225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist