=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346896982
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PALESTINE VASCULAR LAB, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2019
-----------------------------------------------------
Last Update Date | 11/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 WILLOW CREEK PKWY STE 100
-----------------------------------------------------
City | PALESTINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75801-4433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-729-2888
-----------------------------------------------------
Fax | 903-729-2781
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 WILLOW CREEK PKWY STE 100
-----------------------------------------------------
City | PALESTINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75801-4433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-729-2888
-----------------------------------------------------
Fax | 903-729-2781
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF OPERATIONS
-----------------------------------------------------
Name | TONY ROTONDO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 713-539-7477
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------