Healthcare Provider Details

I. General information

NPI: 1700876919
Provider Name (Legal Business Name): VICKIE CLINE OPA-C, LSA, SA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 06/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2317 COBBLECREEK DR
CONROE TX
77384-3703
US

IV. Provider business mailing address

2317 COBBLECREEK DR
CONROE TX
77384-3703
US

V. Phone/Fax

Practice location:
  • Phone: 281-541-8872
  • Fax: 331-625-7932
Mailing address:
  • Phone: 281-541-8872
  • Fax: 331-625-7932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License NumberLSA: SA00167
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: