1093251035 NPI number — ANGEL CARE FAMILY CLINIC, LLC

Table of content: (NPI 1093251035)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093251035 NPI number — ANGEL CARE FAMILY CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANGEL CARE FAMILY CLINIC, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093251035
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8722 SAILING DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUMBLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77346-2792
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-390-4579
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5330 FM 1960 RD E
Provider Second Line Business Practice Location Address:
STE C
Provider Business Practice Location Address City Name:
HUMBLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77346-2502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-390-4579
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/14/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
REYNOLDS
Authorized Official First Name:
SUREE
Authorized Official Middle Name:
HOPITAKKUL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
832-390-4579

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP130655 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: AP130655 . This is a "APRN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".