MEDICARE: PVD DIAGNOSTICS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1326566415
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PVD DIAGNOSTICS, LLC

Provider Business Mailing Address
First Line	:	PO BOX 690804
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78269-0804
Country	:	US
Telephone Number	:	210-451-7525
Fax Number	:	210-451-7526

Provider Business Practice Location Address
First Line	:	18007 W IH 10
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78257-9536
Country	:	US
Telephone Number	:	210-451-7525
Fax Number	:	210-451-7526

Authorized Official
Title or Position	:	CEO
Name	:	PETER VAN DELDEN
Credential	:	MD
Telephone Number	:	210-445-4450

Provider Enumeration Date	:	09/08/2017
Last Update Date	:	10/21/2022

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