Healthcare Provider Details

I. General information

NPI: 1366988412
Provider Name (Legal Business Name): PROVIDENCE MISSION MINISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2017
Last Update Date: 03/08/2020
Certification Date: 03/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 ALPINE ST
COLDSPRING TX
77331-8058
US

IV. Provider business mailing address

PO BOX 1293
NEW CANEY TX
77357-1293
US

V. Phone/Fax

Practice location:
  • Phone: 936-647-2227
  • Fax: 936-647-2202
Mailing address:
  • Phone: 281-774-8785
  • Fax: 832-543-5006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. JENNIFER NGUYEN
Title or Position: BUSINESS ACCOUNT MANAGER
Credential:
Phone: 281-774-8785