1902061575 NPI number — OUTREACH DIAGNOSTIC CLINIC

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 1902061575 NPI number — OUTREACH DIAGNOSTIC CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OUTREACH DIAGNOSTIC CLINIC
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:
1902061575
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5120 WOODWAY DRIVE
Provider Second Line Business Mailing Address:
SUITE 7012
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77056-1791
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-532-7311
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 CRAWFORD ST
Provider Second Line Business Practice Location Address:
SUITE 900
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77002-9011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-651-0870
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KIGGUNDU
Authorized Official First Name:
OMAR
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
713-532-7311

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  M3453 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: F0083 , 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: 197746401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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