Provider Demographics
NPI:1093330607
Name:PALOMA BLANCA PROVIDER SERVICES, LLC
Entity Type:Organization
Organization Name:PALOMA BLANCA PROVIDER SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SYLVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOZANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-645-8068
Mailing Address - Street 1:1101 SHILOH DR. #3 OR P.O. BPX 450152
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78045
Mailing Address - Country:US
Mailing Address - Phone:956-727-8068
Mailing Address - Fax:956-727-8068
Practice Address - Street 1:1101 SHILOH DRIVE
Practice Address - Street 2:# 3
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78045
Practice Address - Country:US
Practice Address - Phone:956-727-8068
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PALOMA BLANCA PROVIDER SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-06-09
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty