Provider Demographics
NPI:1053714915
Name:GUATEVIDA LLC
Entity type:Organization
Organization Name:GUATEVIDA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-695-4942
Mailing Address - Street 1:PO BOX 801403
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75380-1403
Mailing Address - Country:US
Mailing Address - Phone:214-377-8144
Mailing Address - Fax:214-414-2533
Practice Address - Street 1:14330 MIDWAY RD STE 229
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75244-3514
Practice Address - Country:US
Practice Address - Phone:214-377-8144
Practice Address - Fax:214-414-2533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-06
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7495640001Medicare NSC