MEDICARE: ITINA GUIDRY

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	171W00000X	Contractor
2	246RM2200X	Medical Laboratory Technician	165268	TX
3	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1619200409
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ITINA GUIDRY

Provider Business Mailing Address
First Line	:	614 SHADY DALE DR
Second Line	:
City	:	STAFFORD
State	:	TX
Zip	:	77477-5925
Country	:	US
Telephone Number	:	832-276-9238
Fax Number	:

Provider Business Practice Location Address
First Line	:	15011 MONRAD DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77053-1344
Country	:	US
Telephone Number	:	832-276-9238
Fax Number	:

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

Provider Enumeration Date	:	09/10/2009
Last Update Date	:	09/11/2009

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Directions to “ ITINA GUIDRY ” Practice Location

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