Healthcare Provider Details

I. General information

NPI: 1124886676
Provider Name (Legal Business Name): MICAH ALLEN ZIMMERER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2024
Last Update Date: 03/11/2024
Certification Date: 03/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 CITY CENTRAL AVE
CONROE TX
77304-2981
US

IV. Provider business mailing address

5746 LAFITTE RD
EUSTACE TX
75124-6153
US

V. Phone/Fax

Practice location:
  • Phone: 936-202-5202
  • Fax:
Mailing address:
  • Phone: 214-335-0688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: