Provider Demographics
NPI:1205188455
Name:VAL VERDE HEALTH CLINIC
Entity Type:Organization
Organization Name:VAL VERDE HEALTH CLINIC
Other - Org Name:AMISTAD MEDICAL PROFESSIONALS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ADRIAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-774-2505
Mailing Address - Street 1:1200 N BEDELL AVE
Mailing Address - Street 2:
Mailing Address - City:DEL RIO
Mailing Address - State:TX
Mailing Address - Zip Code:78840-4491
Mailing Address - Country:US
Mailing Address - Phone:830-774-2505
Mailing Address - Fax:830-774-2394
Practice Address - Street 1:1200 N BEDELL AVE
Practice Address - Street 2:
Practice Address - City:DEL RIO
Practice Address - State:TX
Practice Address - Zip Code:78840-4491
Practice Address - Country:US
Practice Address - Phone:830-774-2505
Practice Address - Fax:830-774-2394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-12
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX281839501Medicaid
TXTXB110842Medicare PIN