Healthcare Provider Details

I. General information

NPI: 1376254573
Provider Name (Legal Business Name): MEDIQ HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2022
Last Update Date: 12/08/2022
Certification Date: 12/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2445 MERCHANT AVE STE C
ODESSA FL
33556-3466
US

IV. Provider business mailing address

11051 RANCHO PL
FORT WORTH TX
76244-4859
US

V. Phone/Fax

Practice location:
  • Phone: 181-386-2866
  • Fax: 817-887-3487
Mailing address:
  • Phone: 813-862-8668
  • Fax: 817-887-3487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT ALLEN VESCHI
Title or Position: MANAGING DIRECTOR
Credential:
Phone: 813-862-8668