MEDICARE: VALLE LA QUINTA, 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	261QA0600X	Adult Day Care Clinic/Center

General Provider Information

NPI Number	:	1235750423
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VALLE LA QUINTA, LLC

Provider Business Mailing Address
First Line	:	881 S SAM HOUSTON BLVD
Second Line	:
City	:	SAN BENITO
State	:	TX
Zip	:	78586-3062
Country	:	US
Telephone Number	:	956-281-3335
Fax Number	:

Provider Business Practice Location Address
First Line	:	881 S SAM HOUSTON BLVD
Second Line	:
City	:	SAN BENITO
State	:	TX
Zip	:	78586-3062
Country	:	US
Telephone Number	:	956-281-3335
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	PETER ISASSI
Credential	:
Telephone Number	:	956-589-2498

Provider Enumeration Date	:	04/29/2020
Last Update Date	:	04/29/2020

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