Provider Demographics
NPI:1710598917
Name:ONTIVEROS, JAIME FABIAN (PTA)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:FABIAN
Last Name:ONTIVEROS
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 1:4509 N MOOREFIELD RD
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78574-4894
Mailing Address - Country:US
Mailing Address - Phone:956-435-2965
Mailing Address - Fax:
Practice Address - Street 1:2117 E TYLER AVE STE B
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-7212
Practice Address - Country:US
Practice Address - Phone:956-440-0580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2155890225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant