1205907987 NPI number — FAMILY TREE HEALTH CLINIC P A

Table of content: (NPI 1205907987)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205907987 NPI number — FAMILY TREE HEALTH CLINIC P A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY TREE HEALTH CLINIC P A
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:
1205907987
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2911 S SHORE BLVD
Provider Second Line Business Mailing Address:
SUITE 190
Provider Business Mailing Address City Name:
LEAGUE CITY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77573-3922
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-538-8188
Provider Business Mailing Address Fax Number:
281-538-8189

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2911 S SHORE BLVD
Provider Second Line Business Practice Location Address:
SUITE 190
Provider Business Practice Location Address City Name:
LEAGUE CITY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77573-3922
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-538-8188
Provider Business Practice Location Address Fax Number:
281-538-8189
Provider Enumeration Date:
11/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ZAMORA
Authorized Official First Name:
ALVARO
Authorized Official Middle Name:
FRANCISCO
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
281-538-8188

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MDTXJ9936 , 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: 0042LW . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 177836701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com