MEDICARE: VIMALA MATHEW RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WP0808X	Psychiatric/Mental Health Registered Nurse	656974	TX

General Provider Information

NPI Number	:	1053324657
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIMALA MATHEW RN

Provider Business Mailing Address
First Line	:	5807 MARTINIQUE PASS
Second Line	:
City	:	SUGAR LAND
State	:	TX
Zip	:	77479-4159
Country	:	US
Telephone Number	:	281-277-6646
Fax Number	:

Provider Business Practice Location Address
First Line	:	2002 HOLCOMBE ,HOUSTON,TEXAS
Second Line	:	5807 MARTINIQUE PASS
City	:	SUGARLAND
State	:	TX
Zip	:	77479
Country	:	US
Telephone Number	:	281-277-6646
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	07/08/2007

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