Provider Demographics
NPI:1932323599
Name:TANEDO, IRWIN ALIVO
Entity Type:Individual
Prefix:MR
First Name:IRWIN
Middle Name:ALIVO
Last Name:TANEDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 BASSE RD. APT#511
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212
Mailing Address - Country:US
Mailing Address - Phone:210-663-2029
Mailing Address - Fax:
Practice Address - Street 1:902 BANDERA RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78228-4923
Practice Address - Country:US
Practice Address - Phone:210-431-4513
Practice Address - Fax:210-431-4531
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2058013225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant