MEDICARE: BRAESWOOD VACCINE CLINIC,INC

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	208000000X	Pediatrics Physician	G1258	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144462334
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRAESWOOD VACCINE CLINIC,INC

Provider Business Mailing Address
First Line	:	1940 FOUNTAIN VIEW DR
Second Line	:	UNIT 204
City	:	HOUSTON
State	:	TX
Zip	:	77057-3206
Country	:	US
Telephone Number	:	832-251-0500
Fax Number	:	832-251-0503

Provider Business Practice Location Address
First Line	:	8622 S BRAESWOOD BLVD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77031-1301
Country	:	US
Telephone Number	:	832-251-0500
Fax Number	:	832-251-0503

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. HARMINDER S CHANA
Credential	:	MD
Telephone Number	:	832-251-0500

Provider Enumeration Date	:	04/02/2009
Last Update Date	:	11/09/2009

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