=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104093913
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIVYATISH PRIMARY CARE HEALTH SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2008
-----------------------------------------------------
Last Update Date | 05/12/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 E SAN ANTONIO ST STE 304W
-----------------------------------------------------
City | VICTORIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77901-6040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-576-3680
-----------------------------------------------------
Fax | 361-576-4219
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3685
-----------------------------------------------------
City | VICTORIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77903-3685
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-576-3680
-----------------------------------------------------
Fax | 361-576-4219
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ARUN JAIN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 361-576-3680
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | L8086
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------