Provider Demographics
NPI:1639228984
Name:VITALUS AIRWAY 984 INC
Entity Type:Organization
Organization Name:VITALUS AIRWAY 984 INC
Other - Org Name:PULMONARYRX, BOLYARDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OF STAFF
Authorized Official - Prefix:
Authorized Official - First Name:RAQUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-968-2300
Mailing Address - Street 1:2727 ALLEN PKWY STE 1915
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77019-2177
Mailing Address - Country:US
Mailing Address - Phone:281-968-2300
Mailing Address - Fax:281-968-2301
Practice Address - Street 1:10019 MAIN ST STE A9-A
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77025
Practice Address - Country:US
Practice Address - Phone:281-968-2300
Practice Address - Fax:281-968-2301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0034083332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX155824901Medicaid
TX155824902Medicaid
TX155824902Medicaid