1548422439 NPI number — VITAL HEALTH LLP

Table of content: (NPI 1548422439)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548422439 NPI number — VITAL HEALTH LLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VITAL HEALTH LLP
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:
CARLOS R VILLALTA, MD PEDIATRIC CLINIC
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:
1548422439
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/26/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1632
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MISSION
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78573-0029
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-584-3231
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
32685 US HIGHWAY 281 N STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BULVERDE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78163-3272
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-742-7300
Provider Business Practice Location Address Fax Number:
210-742-7301
Provider Enumeration Date:
07/01/2008

Additional Information

Authorized Official

Authorized Official Last Name:
VILLALTA
Authorized Official First Name:
CARLOS
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
210-742-7300

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 151603101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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