=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326438003
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | S.T.C. MEDICUS ENTERPRISES, LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2015
-----------------------------------------------------
Last Update Date | 03/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4347 PHELAN BLVD STE 101
-----------------------------------------------------
City | BEAUMONT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77707-2159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-291-8880
-----------------------------------------------------
Fax | 409-291-8829
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4347 PHELAN BLVD STE 104
-----------------------------------------------------
City | BEAUMONT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77707-2159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-291-8880
-----------------------------------------------------
Fax | 409-291-8829
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. SAUL AVILA
-----------------------------------------------------
Credential | C.R.T
-----------------------------------------------------
Telephone | 409-291-8880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------