MEDICARE: GERIATRIC AND PALLIATIVE MEDICAL CARE OF TEXAS 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	261QM2500X	Medical Specialty Clinic/Center

General Provider Information

NPI Number	:	1821459827
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GERIATRIC AND PALLIATIVE MEDICAL CARE OF TEXAS 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	:	FOUNDER/CEO
Name	:	DR. TANPRASERTH VATANADILOK
Credential	:	D.N.P.
Telephone Number	:	210-379-7340

Provider Enumeration Date	:	03/18/2016
Last Update Date	:	03/18/2016

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