Organization
GRAPEVINEVERSE IOM LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. AUGUSTO C LASTIMOSA M.D. (MANAGING MEMBER)
(817) 366-4777
Entity
Organization
Contact information
Practice address
500 THROCKMORTON STREET, UNIT 3309, FORT WORTH, TX 76102
(817) 908-8124
(817) 885-7339
Mailing address
500 THROCKMORTON STREET, UNIT 3309, FORT WORTH, TX 76102
(817) 908-8124
(817) 885-7339
Taxonomy
Speciality
Code
Description
License number
State
246ZS0410X
Surgical Technologist
Primary
—
—
Other
Enumeration date
02/01/2019
Last updated
02/01/2019
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