1174966915 NPI number — IDIC HEALTHCARE, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174966915 NPI number — IDIC HEALTHCARE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IDIC HEALTHCARE, PLLC
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:
IDIC HEALTHCARE, PLLC
Provider Other Organization Name Type Code:
5
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:
1174966915
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5726 SAGAMORE BAY LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77469-7398
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-248-4636
Provider Business Mailing Address Fax Number:
866-804-7241

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
627 W. 19TH ST.
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77008-3613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-248-4636
Provider Business Practice Location Address Fax Number:
866-804-7241
Provider Enumeration Date:
04/11/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HOUSEWORTH
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
832-248-4636

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0855X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 31626 . This is a "LBSW LICENSE NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 5210 . This is a "LMFT LICENSE NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".