Healthcare Provider Details

I. General information

NPI: 1386579357
Provider Name (Legal Business Name): VISAR LICA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2026
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 PHILOMENA ST
AUSTIN TX
78723-3574
US

IV. Provider business mailing address

22071 RIVER OAKS DR APT A12
ROCKY RIVER OH
44116-3156
US

V. Phone/Fax

Practice location:
  • Phone: 737-434-2436
  • Fax:
Mailing address:
  • Phone: 216-303-0372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: