Healthcare Provider Details

I. General information

NPI: 1538843842
Provider Name (Legal Business Name): VACQUERO MEDICAL 1 PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2023
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 BOLAND ST STE 211
FT WORTH TX
76107-1265
US

IV. Provider business mailing address

111 BOLAND ST STE 211
FT WORTH TX
76107-1265
US

V. Phone/Fax

Practice location:
  • Phone: 817-529-8511
  • Fax: 903-328-6568
Mailing address:
  • Phone: 817-529-8511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204R00000X
TaxonomyElectrodiagnostic Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: GINA SULLIVAN
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 903-259-0550