Provider Demographics
NPI:1407558638
Name:SALAS, ESTEBAN RICARDO
Entity Type:Individual
Prefix:
First Name:ESTEBAN
Middle Name:RICARDO
Last Name:SALAS
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 1:2234 ALTA CANADA LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76177-8237
Mailing Address - Country:US
Mailing Address - Phone:817-492-9383
Mailing Address - Fax:
Practice Address - Street 1:3529 DENTON HWY STE D
Practice Address - Street 2:
Practice Address - City:HALTOM CITY
Practice Address - State:TX
Practice Address - Zip Code:76117-3293
Practice Address - Country:US
Practice Address - Phone:817-759-0707
Practice Address - Fax:817-759-0828
Is Sole Proprietor?:No
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1092033164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse