Healthcare Provider Details

I. General information

NPI: 1912192154
Provider Name (Legal Business Name): CENTER MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 09/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2106 CENTER ST
DEER PARK TX
77536-4164
US

IV. Provider business mailing address

2106 CENTER ST
DEER PARK TX
77536-4164
US

V. Phone/Fax

Practice location:
  • Phone: 281-476-4266
  • Fax: 281-476-4278
Mailing address:
  • Phone: 281-476-4266
  • Fax: 281-476-4278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberE4534
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License NumberE4534
License Number StateTX

VIII. Authorized Official

Name: ROBERT W MOERS
Title or Position: MEDICAL PROVIDER
Credential: M.D.
Phone: 281-476-4266