Provider Demographics
NPI:1174673313
Name:VALLEY OSTOMY SUPPLY, INC
Entity Type:Organization
Organization Name:VALLEY OSTOMY SUPPLY, INC
Other - Org Name:LIFETIME HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CESAR
Authorized Official - Middle Name:
Authorized Official - Last Name:ONTIVEROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-972-0244
Mailing Address - Street 1:1138 E EXPRESSWAY 83
Mailing Address - Street 2:SUITE A
Mailing Address - City:PHARR
Mailing Address - State:TX
Mailing Address - Zip Code:78577-6518
Mailing Address - Country:US
Mailing Address - Phone:956-283-1253
Mailing Address - Fax:956-781-4973
Practice Address - Street 1:1138 E EXPRESSWAY 83
Practice Address - Street 2:SUITE A
Practice Address - City:PHARR
Practice Address - State:TX
Practice Address - Zip Code:78577-6518
Practice Address - Country:US
Practice Address - Phone:956-283-1253
Practice Address - Fax:956-781-4973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0080136332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX010181802Medicaid
TX010181801Medicaid
TX010181802Medicaid