Provider Demographics
NPI:1396842761
Name:SEVENTEEN LAC INC.
Entity Type:Organization
Organization Name:SEVENTEEN LAC INC.
Other - Org Name:CARE STAT;'S BUENA AVENTURA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:CANTU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-727-1900
Mailing Address - Street 1:PO BOX 450249
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78045-0249
Mailing Address - Country:US
Mailing Address - Phone:956-727-1900
Mailing Address - Fax:956-727-1718
Practice Address - Street 1:2412 JACAMAN RD
Practice Address - Street 2:SUITE 104
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-6229
Practice Address - Country:US
Practice Address - Phone:956-727-1900
Practice Address - Fax:956-727-1718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX011500251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX74-7295OtherMEDICARE CERTIFICATION OR PTAN