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NPI Code Detail

MEDICARE: THE 21 CLUB OF CNY INC

MEDICARE: THE 21 CLUB OF CNY 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
1291U00000XClinical Medical Laboratory

General Provider Information

NPI Number : 1700743325
Entity Type Code : Organization
Provider Name (Legal Business Name) : THE 21 CLUB OF CNY INC
Provider Business Mailing Address
First Line : 12828 WILLOW CENTRE DR STE D
Second Line :
City : HOUSTON
State : TX
Zip : 77066-3043
Country : US
Telephone Number : 713-766-2796
Fax Number : 712-219-5827
Provider Business Practice Location Address
First Line : 12828 WILLOW CENTRE DR STE D
Second Line :
City : HOUSTON
State : TX
Zip : 77066-3043
Country : US
Telephone Number : 713-766-2796
Fax Number : 712-219-5827
Authorized Official
Title or Position : OWNER
Name : CAROLYN WALDRON
Credential :
Telephone Number : 713-766-2796
Provider Enumeration Date : 01/06/2026
Last Update Date : 02/13/2026

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Directions to “THE 21 CLUB OF CNY INC ” Practice Location

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