MEDICARE: VICDOS HEALTH PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	171W00000X	Contractor
2	251E00000X	Home Health Agency
3	251J00000X	Nursing Care Agency
4	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1790566966
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VICDOS HEALTH PLLC

Provider Business Mailing Address
First Line	:	19179 BLANCO RD STE 105
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-4009
Country	:	US
Telephone Number	:	210-985-6886
Fax Number	:	210-899-8013

Provider Business Practice Location Address
First Line	:	7750 CULEBRA RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78251-1468
Country	:	US
Telephone Number	:	210-985-6886
Fax Number	:	210-899-8013

Authorized Official
Title or Position	:	OWNER
Name	:	HERITAGE EWAOLUWA OGUNMOLA
Credential	:	RN
Telephone Number	:	317-607-5447

Provider Enumeration Date	:	10/12/2023
Last Update Date	:	10/29/2024

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