Provider Demographics
NPI:1073095105
Name:VILLARREAL, JORGE LUIS (PTA)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name:VILLARREAL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3014 VIOLA DR
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78574-2072
Mailing Address - Country:US
Mailing Address - Phone:956-655-5291
Mailing Address - Fax:
Practice Address - Street 1:820 CAMELOT DR
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-8400
Practice Address - Country:US
Practice Address - Phone:956-423-2663
Practice Address - Fax:956-440-8272
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2045169225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty