Provider Demographics
NPI:1669661757
Name:WELCH, BIANELLY VALDEZ
Entity Type:Individual
Prefix:
First Name:BIANELLY
Middle Name:VALDEZ
Last Name:WELCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12209 TWIN CREEK RD
Mailing Address - Street 2:SUITE H
Mailing Address - City:MANCHACA
Mailing Address - State:TX
Mailing Address - Zip Code:78652-3783
Mailing Address - Country:US
Mailing Address - Phone:512-458-1414
Mailing Address - Fax:512-458-5550
Practice Address - Street 1:12209 TWIN CREEK RD
Practice Address - Street 2:SUITE H
Practice Address - City:MANCHACA
Practice Address - State:TX
Practice Address - Zip Code:78652-3783
Practice Address - Country:US
Practice Address - Phone:512-458-1414
Practice Address - Fax:512-458-5550
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-15
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX208482401Medicaid
TX208482402Medicaid
TX262321981OtherTRICARE
TX208482402Medicaid