Provider Demographics
NPI:1972777548
Name:MRS.GRACIELA TERESA NIETO
Entity Type:Organization
Organization Name:MRS.GRACIELA TERESA NIETO
Other - Org Name:MEDICAL X-RAY ON WHEELS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GRACIELA
Authorized Official - Middle Name:TERESA
Authorized Official - Last Name:NIETO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-535-2818
Mailing Address - Street 1:PO BOX 1886
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78551-1886
Mailing Address - Country:US
Mailing Address - Phone:956-722-9729
Mailing Address - Fax:956-722-9990
Practice Address - Street 1:1405 E LYON ST
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78040-2733
Practice Address - Country:US
Practice Address - Phone:956-722-9729
Practice Address - Fax:956-722-9990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR29718335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX185111501Medicaid
TX185111501Medicaid