Healthcare Provider Details

I. General information

NPI: 1053772236
Provider Name (Legal Business Name): VATANADILOK ENTERPRISE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2016
Last Update Date: 03/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4879 CORIAN SPRINGS DR
SAN ANTONIO TX
78247-5599
US

IV. Provider business mailing address

4879 CORIAN SPRINGS DR
SAN ANTONIO TX
78247-5599
US

V. Phone/Fax

Practice location:
  • Phone: 210-379-7340
  • Fax:
Mailing address:
  • Phone: 210-379-7340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number611125
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberH3885
License Number StateTX

VIII. Authorized Official

Name: TANPRASERTH VATANADILOK
Title or Position: NURSE PRACTITIONER
Credential: N.P.
Phone: 972-687-9138