Healthcare Provider Details

I. General information

NPI: 1679767248
Provider Name (Legal Business Name): BRAZOS TECH MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 08/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 NORTH BROOKS
BRAZORIA TX
77422
US

IV. Provider business mailing address

PO BOX 1235
BRAZORIA TX
77422-1235
US

V. Phone/Fax

Practice location:
  • Phone: 979-798-9103
  • Fax: 979-798-9109
Mailing address:
  • Phone: 979-798-9103
  • Fax: 979-798-9109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10723
License Number StateTX

VIII. Authorized Official

Name: CAROLYN HUISMAN
Title or Position: OWNER
Credential:
Phone: 979-798-9103