1174529945 NPI number — VICTOR GOMEZ VANVAL ENTERPRISE

Table of content: (NPI 1174529945)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174529945 NPI number — VICTOR GOMEZ VANVAL ENTERPRISE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VICTOR GOMEZ VANVAL ENTERPRISE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
VANVAL MEDICAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174529945
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11601 PELLICANO DR
Provider Second Line Business Mailing Address:
SUITE B8
Provider Business Mailing Address City Name:
EL PASO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79936-6279
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
915-593-3556
Provider Business Mailing Address Fax Number:
915-595-6556

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11601 PELLICANO DR
Provider Second Line Business Practice Location Address:
SUITE B8
Provider Business Practice Location Address City Name:
EL PASO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79936-6279
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-593-3556
Provider Business Practice Location Address Fax Number:
915-595-6556
Provider Enumeration Date:
06/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GOMEZ
Authorized Official First Name:
VICTOR
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
915-593-3556

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  0055163 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BP3500X , with the licence number: 0055163 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BX2000X , with the licence number: 0055163 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 144538901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 144537101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 531034 . This is a "BLUE CROSS BLUE SHIELD TX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: QMP000003931980 . This is a "MOLINA HEALTHCARE PLAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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