Healthcare Provider Details

I. General information

NPI: 1063803138
Provider Name (Legal Business Name): HOUSTON LUNG CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2015
Last Update Date: 02/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 TOMMY STALNAKER DR
WARNER ROBINS GA
31088-9179
US

IV. Provider business mailing address

92 TOMMY STALNAKER DR
WARNER ROBINS GA
31088-9179
US

V. Phone/Fax

Practice location:
  • Phone: 478-333-2522
  • Fax: 478-333-3160
Mailing address:
  • Phone: 478-333-2522
  • Fax: 478-333-3160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number052467
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number052467
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number052467
License Number StateGA

VIII. Authorized Official

Name: RODRIGO E MORALES
Title or Position: OWNER/PHYSICIAN
Credential: MD
Phone: 478-333-2522