MEDICARE: GUATEVIDA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BC3200X	Customized Equipment (DME)
2	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1053714915
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GUATEVIDA LLC

Provider Business Mailing Address
First Line	:	PO BOX 801403
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75380-1403
Country	:	US
Telephone Number	:	214-377-8144
Fax Number	:	214-414-2533

Provider Business Practice Location Address
First Line	:	14330 MIDWAY RD STE 229
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75244-3514
Country	:	US
Telephone Number	:	214-377-8144
Fax Number	:	214-414-2533

Authorized Official
Title or Position	:	OWNER
Name	:	JOHN RILEY
Credential	:
Telephone Number	:	214-695-4942

Provider Enumeration Date	:	10/06/2014
Last Update Date	:	12/05/2024

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