1871290825 NPI number — CLINICA FAMILIAR LA LUZ LLC

Table of content: (NPI 1871290825)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871290825 NPI number — CLINICA FAMILIAR LA LUZ LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLINICA FAMILIAR LA LUZ LLC
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:
6
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:
1871290825
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29310 PRAIRIE ROSE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KATY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77494-7384
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-937-5596
Provider Business Mailing Address Fax Number:
832-937-5596

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
29310 PRAIRIE ROSE CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KATY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77494-7384
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-937-5596
Provider Business Practice Location Address Fax Number:
832-937-5596
Provider Enumeration Date:
02/09/2023

Additional Information

Authorized Official

Authorized Official Last Name:
BASULTO BASULTO
Authorized Official First Name:
NORBE
Authorized Official Middle Name:
LUIS
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
713-660-1603

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1861628505 . This is a "BLUE CROSS AND BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1861628505 . This is a "MOLINA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1861628505 . This is a "OSCAR" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1861628505 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1861628505 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1861628505 . This is a "COMMUNITY HEALTH CHOICE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1861628505 . This is a "CIGNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1861628505 . This is a "AMBETTER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1861628505 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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