Provider Demographics
NPI:1679856579
Name:RENTERIA, AGUSTIN JR (BS ASST SLP)
Entity Type:Individual
Prefix:
First Name:AGUSTIN
Middle Name:
Last Name:RENTERIA
Suffix:JR
Gender:M
Credentials:BS ASST SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 S CYNTHIA ST
Mailing Address - Street 2:STE A
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78503-1278
Mailing Address - Country:US
Mailing Address - Phone:956-630-6300
Mailing Address - Fax:956-630-3443
Practice Address - Street 1:2001 S CYNTHIA ST
Practice Address - Street 2:STE A
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78503-1278
Practice Address - Country:US
Practice Address - Phone:956-630-6300
Practice Address - Fax:956-630-3443
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX362412355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX167033301Medicaid