Healthcare Provider Details

I. General information

NPI: 1740661453
Provider Name (Legal Business Name): NASA HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2015
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

985 NASA PKWY
HOUSTON TX
77058-3039
US

IV. Provider business mailing address

985 NASA PKWY
HOUSTON TX
77058-3039
US

V. Phone/Fax

Practice location:
  • Phone: 713-893-6214
  • Fax:
Mailing address:
  • Phone: 281-218-6777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BRAD PETERSON
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 713-893-6214