Healthcare Provider Details

I. General information

NPI: 1871775486
Provider Name (Legal Business Name): MAINLAND ALLERGY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2007
Last Update Date: 12/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914 FM 517 RD W
DICKINSON TX
77539-3923
US

IV. Provider business mailing address

914 FM 517 RD W
DICKINSON TX
77539-3923
US

V. Phone/Fax

Practice location:
  • Phone: 281-337-1512
  • Fax: 281-534-1472
Mailing address:
  • Phone: 281-337-1512
  • Fax: 281-534-1472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberH3976
License Number StateTX

VIII. Authorized Official

Name: MRS. SUSAN L ANDREW
Title or Position: MD
Credential: MD
Phone: 281-337-1512