1831327014 NPI number — MIRAGE HEALTHCARE SERVICES INC

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 1831327014 NPI number — MIRAGE HEALTHCARE SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIRAGE HEALTHCARE SERVICES INC
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:
1831327014
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12808 W AIRPORT BLVD
Provider Second Line Business Mailing Address:
SUITE 345
Provider Business Mailing Address City Name:
SUGAR LAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77478-6184
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-234-7824
Provider Business Mailing Address Fax Number:
713-234-7825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2825 WILCREST DR STE 621
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77042-6059
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-867-7970
Provider Business Practice Location Address Fax Number:
713-867-7970
Provider Enumeration Date:
06/26/2009

Additional Information

Authorized Official

Authorized Official Last Name:
AJAERO
Authorized Official First Name:
EVARISTUS
Authorized Official Middle Name:
N
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
713-867-7970

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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