Provider Demographics
NPI:1053772236
Name:VATANADILOK ENTERPRISE LLC
Entity type:Organization
Organization Name:VATANADILOK ENTERPRISE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:TANPRASERTH
Authorized Official - Middle Name:
Authorized Official - Last Name:VATANADILOK
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:972-687-9138
Mailing Address - Street 1:4879 CORIAN SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-5599
Mailing Address - Country:US
Mailing Address - Phone:210-379-7340
Mailing Address - Fax:
Practice Address - Street 1:4879 CORIAN SPRINGS DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78247-5599
Practice Address - Country:US
Practice Address - Phone:210-379-7340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH3885207RG0300X
TX611125363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty