MEDICARE: HARDY OAK PVDM ENTERPRISES, 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	261QE0002X	Emergency Care Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	160490	OTHER	TX	TEXAS FACILITY LICENSE

General Provider Information

NPI Number	:	1952903197
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HARDY OAK PVDM ENTERPRISES, LLC

Provider Business Mailing Address
First Line	:	PO BOX 690804
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78269-0804
Country	:	US
Telephone Number	:	210-626-8782
Fax Number	:

Provider Business Practice Location Address
First Line	:	23511 HARDY OAK BLVD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-1928
Country	:	US
Telephone Number	:	210-626-8782
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	PETER VAN DELDEN
Credential	:	MD
Telephone Number	:	210-373-9647

Provider Enumeration Date	:	11/12/2020
Last Update Date	:	06/12/2025

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