MEDICARE: SYNERGENX HEALTH - ATASCOCITA 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

General Provider Information

NPI Number	:	1811521438
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SYNERGENX HEALTH - ATASCOCITA LLC

Provider Business Mailing Address
First Line	:	16131 N ELDRIDGE PKWY STE 100
Second Line	:
City	:	TOMBALL
State	:	TX
Zip	:	77377-9130
Country	:	US
Telephone Number	:	281-429-8522
Fax Number	:	281-970-5913

Provider Business Practice Location Address
First Line	:	18321 W LAKE HOUSTON PKWY STE 420
Second Line	:
City	:	HUMBLE
State	:	TX
Zip	:	77346-3587
Country	:	US
Telephone Number	:	832-639-1553
Fax Number	:	832-639-1558

Authorized Official
Title or Position	:	MANAGER
Name	:	WELTON WAYNE WILSON
Credential	:
Telephone Number	:	281-429-8522

Provider Enumeration Date	:	02/24/2020
Last Update Date	:	02/19/2021

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