=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225117765
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORAZON DEL VALLE DME LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2006
-----------------------------------------------------
Last Update Date | 01/09/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1514 S. 77 SUNSHINE STRIP STE 24
-----------------------------------------------------
City | HARLINGEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-797-3730
-----------------------------------------------------
Fax | 956-797-3779
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1514 S. 77 SUNSHINE STRIP STE 24
-----------------------------------------------------
City | HARLINGEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78550-5294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-797-3730
-----------------------------------------------------
Fax | 956-797-3779
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RODNEY MESQUIAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 956-797-3730
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 0077358
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332BP3500X
-----------------------------------------------------
Taxonomy Name | Parenteral & Enteral Nutrition Supplies (DME)
-----------------------------------------------------
License Number | 0077358
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------