=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053714915
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GUATEVIDA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2014
-----------------------------------------------------
Last Update Date | 12/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14330 MIDWAY RD STE 229
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75244-3514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-377-8144
-----------------------------------------------------
Fax | 214-414-2533
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 801403
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75380-1403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-377-8144
-----------------------------------------------------
Fax | 214-414-2533
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOHN RILEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 214-695-4942
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------