Provider Demographics
NPI:1891205852
Name:CONTRERAS, MARCO ALEXANDER (LMT)
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:ALEXANDER
Last Name:CONTRERAS
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 1:609 VALLE DE BRAVO PL
Mailing Address - Street 2:
Mailing Address - City:HORIZON CITY
Mailing Address - State:TX
Mailing Address - Zip Code:79928-4700
Mailing Address - Country:US
Mailing Address - Phone:915-245-9741
Mailing Address - Fax:
Practice Address - Street 1:125 N KENAZO AVE
Practice Address - Street 2:
Practice Address - City:HORIZON CITY
Practice Address - State:TX
Practice Address - Zip Code:79928-5404
Practice Address - Country:US
Practice Address - Phone:915-245-9741
Practice Address - Fax:915-245-9741
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT123288225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXMT123288OtherLICENSED MASSAGE THERAPIST