Healthcare Provider Details

I. General information

NPI: 1164726956
Provider Name (Legal Business Name): 290 MANGUM HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2011
Last Update Date: 01/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5005 W 34TH ST SUITE 102C
HOUSTON TX
77092-4200
US

IV. Provider business mailing address

5005 W 34TH ST SUITE 102C
HOUSTON TX
77092-4200
US

V. Phone/Fax

Practice location:
  • Phone: 713-682-2212
  • Fax: 713-682-9997
Mailing address:
  • Phone: 713-682-2212
  • Fax: 713-682-9997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberPA01537
License Number StateTX

VIII. Authorized Official

Name: MR. TABARE D TABAR
Title or Position: MANAGER
Credential: P A
Phone: 713-682-2212