=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063849800
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDSOLID PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2013
-----------------------------------------------------
Last Update Date | 12/09/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 699 WALNUT ST FL 4
-----------------------------------------------------
City | DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50309-3929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-708-6101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17503 LA CANTERA PKWY SUITE 104-510
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78257-8207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-661-4847
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. JUAN A ACOSTA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 515-708-6101
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 38249
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------