MEDICARE: PROVIDENCE MISSION MINISTRY LLC

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	261QP2300X	Primary Care Clinic/Center

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	:	1366988412
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE MISSION MINISTRY LLC

Provider Business Mailing Address
First Line	:	PO BOX 1293
Second Line	:
City	:	NEW CANEY
State	:	TX
Zip	:	77357-1293
Country	:	US
Telephone Number	:	281-774-8785
Fax Number	:	832-543-5006

Provider Business Practice Location Address
First Line	:	21 ALPINE ST
Second Line	:
City	:	COLDSPRING
State	:	TX
Zip	:	77331-8058
Country	:	US
Telephone Number	:	936-647-2227
Fax Number	:	936-647-2202

Authorized Official
Title or Position	:	BUSINESS ACCOUNT MANAGER
Name	:	MRS. JENNIFER NGUYEN
Credential	:
Telephone Number	:	281-774-8785

Provider Enumeration Date	:	01/12/2017
Last Update Date	:	03/08/2020

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Directions to “PROVIDENCE MISSION MINISTRY LLC ” Practice Location

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