1629267752 NPI number — CLEAR LAKE ENT, P.A

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 1629267752 NPI number — CLEAR LAKE ENT, P.A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLEAR LAKE ENT, 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:
1629267752
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 580451
Provider Second Line Business Mailing Address:
LOCK BOX 157102
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77258-0451
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-335-7755
Provider Business Mailing Address Fax Number:
281-335-7766

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18100 SAINT JOHN DR
Provider Second Line Business Practice Location Address:
SUITE 240
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77058-3631
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-335-7755
Provider Business Practice Location Address Fax Number:
281-335-7766
Provider Enumeration Date:
10/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JIMENEZ
Authorized Official First Name:
ALFREDO
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
281-335-7755

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  J4653 , 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: 8K6340 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0029KV . This is a "MCARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: F68110 . This is a "UPIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 10023864 . This is a "AMERIGROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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