Healthcare Provider Details

I. General information

NPI: 1841643897
Provider Name (Legal Business Name): VIVA ADVANCED HEALTHCARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2016
Last Update Date: 07/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 W OKLAHOMA AVE
MILWAUKEE WI
53215-4617
US

IV. Provider business mailing address

PO BOX 639
THIENSVILLE WI
53092-0639
US

V. Phone/Fax

Practice location:
  • Phone: 414-551-2911
  • Fax: 414-384-3404
Mailing address:
  • Phone: 414-247-9005
  • Fax: 414-247-9004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number47171
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number47171
License Number StateWI

VIII. Authorized Official

Name: MANUEL D THOMAS
Title or Position: PRESIDENT/OWNER
Credential: MD
Phone: 414-551-2911