Healthcare Provider Details

I. General information

NPI: 1578836516
Provider Name (Legal Business Name): SIVA PARUCHURI LSA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2012
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 LAVON DR
GRAPEVINE TX
76051-1123
US

IV. Provider business mailing address

1001 LAVON DR
GRAPEVINE TX
76051-1123
US

V. Phone/Fax

Practice location:
  • Phone: 214-227-2457
  • Fax: 214-764-0880
Mailing address:
  • Phone: 214-227-2457
  • Fax: 214-764-0880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberSA00302
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License NumberSA00302
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: