Provider Demographics
NPI:1902088552
Name:JEANE, RITA A
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:A
Last Name:JEANE
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:PO BOX 103
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:TX
Mailing Address - Zip Code:77517-0103
Mailing Address - Country:US
Mailing Address - Phone:409-789-8528
Mailing Address - Fax:409-925-3904
Practice Address - Street 1:16526 COWAN RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:TX
Practice Address - Zip Code:77517-2769
Practice Address - Country:US
Practice Address - Phone:409-789-8528
Practice Address - Fax:409-925-3904
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-05
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0041655332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX016964101Medicaid
TX016964101Medicaid