Provider Demographics
NPI:1437291572
Name:MEDVANTX,INC.
Entity type:Organization
Organization Name:MEDVANTX,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIR. OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:HEINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-625-2990
Mailing Address - Street 1:5810 NANCY RIDGE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-2834
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:116 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEECHBURG
Practice Address - State:PA
Practice Address - Zip Code:15656-1333
Practice Address - Country:US
Practice Address - Phone:724-845-1211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS008408L332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site