Basic Information
| Provider Information | |||||||||
| NPI: | 1598826018 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANTAGE INFUSION SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8080 TRISTAR DRIVE | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750632823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9728150461 | ||||||||
| FaxNumber: | 8773025251 | ||||||||
| Practice Location | |||||||||
| Address1: | 6019 RANDOLPH BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782335719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105997276 | ||||||||
| FaxNumber: | 2105998621 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 06/21/2013 | ||||||||
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| AuthorizedOfficialLastName: | GLYNN | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9492736528 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336H0001X | 16174 | TX | Y | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 0946816-02 | 05 | TX | MEDICAID | 0145435-01 | 05 | TX | MEDICAID | 0788788-01 | 05 | TX | MEDICAID | 0946816-01 | 05 | TX | MEDICAID |