MEDICARE: VATANADILOK ENTERPRISE 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	363LF0000X	Family Nurse Practitioner	611125	TX
2	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	H3885	TX

General Provider Information

NPI Number	:	1053772236
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VATANADILOK ENTERPRISE LLC

Provider Business Mailing Address
First Line	:	4879 CORIAN SPRINGS DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78247-5599
Country	:	US
Telephone Number	:	210-379-7340
Fax Number	:

Provider Business Practice Location Address
First Line	:	4879 CORIAN SPRINGS DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78247-5599
Country	:	US
Telephone Number	:	210-379-7340
Fax Number	:

Authorized Official
Title or Position	:	NURSE PRACTITIONER
Name	:	TANPRASERTH VATANADILOK
Credential	:	N.P.
Telephone Number	:	972-687-9138

Provider Enumeration Date	:	03/15/2016
Last Update Date	:	03/15/2016

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