Provider Demographics
NPI:1740786235
Name:ONTIVEROZ, JERMAN (LMT)
Entity Type:Individual
Prefix:
First Name:JERMAN
Middle Name:
Last Name:ONTIVEROZ
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3873 GWENDOLYN DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79938-9041
Mailing Address - Country:US
Mailing Address - Phone:915-642-3936
Mailing Address - Fax:
Practice Address - Street 1:9611 ACER AVE STE 118
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-6720
Practice Address - Country:US
Practice Address - Phone:915-642-3936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXLMT125722225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist