1184644098 NPI number — CLEAR LAKE EMERGENCY MEDICAL CORPS

Table of content: (NPI 1184644098)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184644098 NPI number — CLEAR LAKE EMERGENCY MEDICAL CORPS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLEAR LAKE EMERGENCY MEDICAL CORPS
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:
CLEAR LAKE EMERGENCY MEDICAL CORPS.
Provider Other Organization Name Type Code:
3
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:
1184644098
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16920 N TEXAS AVE STE C14
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEBSTER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77598-4016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-615-8006
Provider Business Mailing Address Fax Number:
281-488-3080

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
951 FM 646 EAST
Provider Second Line Business Practice Location Address:
SUITE A7
Provider Business Practice Location Address City Name:
DICKINSON, TX 77539
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77539-4016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-204-7794
Provider Business Practice Location Address Fax Number:
832-932-1576
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HUNTER
Authorized Official First Name:
ROY
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF OPERATIONS OFFICER
Authorized Official Telephone Number:
281-204-7794

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  101019 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3416L0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 514783 . This is a "BC/BS OF TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 088228401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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