Provider Demographics
NPI:1295516516
Name:PANTOJA LUQUEZ, YANELIS
Entity type:Individual
Prefix:
First Name:YANELIS
Middle Name:
Last Name:PANTOJA LUQUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11218 HERALD SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77099-1616
Mailing Address - Country:US
Mailing Address - Phone:832-938-1643
Mailing Address - Fax:
Practice Address - Street 1:11218 HERALD SQUARE DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77099-1616
Practice Address - Country:US
Practice Address - Phone:832-938-1643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT129062225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty