1912677550 NPI number — HERMOSA VICTORIA PROVIDER AGENCY LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912677550 NPI number — HERMOSA VICTORIA PROVIDER AGENCY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HERMOSA VICTORIA PROVIDER AGENCY LLC
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:
Provider Other Organization Name Type Code:
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:
1912677550
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1960 ZENAIDA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCALLEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78504-5625
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-321-9067
Provider Business Mailing Address Fax Number:
956-992-1327

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2511 BUDDY OWENS AVE STE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCALLEN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78504-5427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-321-9067
Provider Business Practice Location Address Fax Number:
956-992-1327
Provider Enumeration Date:
09/15/2021

Additional Information

Authorized Official

Authorized Official Last Name:
HERNANDEZ
Authorized Official First Name:
JAVIER
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
956-321-9067

Provider Taxonomy Codes

  • Taxonomy code: 3747P1801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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