Provider Demographics
NPI:1841643897
Name:VIVA ADVANCED HEALTHCARE INC
Entity type:Organization
Organization Name:VIVA ADVANCED HEALTHCARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-551-2911
Mailing Address - Street 1:PO BOX 639
Mailing Address - Street 2:
Mailing Address - City:THIENSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53092-0639
Mailing Address - Country:US
Mailing Address - Phone:414-247-9005
Mailing Address - Fax:414-247-9004
Practice Address - Street 1:1107 W OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4617
Practice Address - Country:US
Practice Address - Phone:414-551-2911
Practice Address - Fax:414-384-3404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-14
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47171208000000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1790870558Medicaid