Provider Demographics
NPI:1720231442
Name:VIVA MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:VIVA MEDICAL GROUP, LLC
Other - Org Name:VIVA PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EFREM
Authorized Official - Middle Name:L
Authorized Official - Last Name:COLMENERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-861-1000
Mailing Address - Street 1:275 W CAMPBELL RD STE 400
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-3581
Mailing Address - Country:US
Mailing Address - Phone:469-341-7772
Mailing Address - Fax:
Practice Address - Street 1:275 W CAMPBELL RD STE 400
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-3581
Practice Address - Country:US
Practice Address - Phone:469-341-7772
Practice Address - Fax:972-378-2111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-25
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX012429251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX199481601Medicaid