Healthcare Provider Details

I. General information

NPI: 1710655139
Provider Name (Legal Business Name): INCOGNITO SPA CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2021
Last Update Date: 08/31/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 ARBOR ST
HOUSTON TX
77004-6026
US

IV. Provider business mailing address

2201 ARBOR ST
HOUSTON TX
77004-6026
US

V. Phone/Fax

Practice location:
  • Phone: 833-430-4807
  • Fax: 833-430-4807
Mailing address:
  • Phone: 833-430-4807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LATASHA KRAUTH
Title or Position: OWNER
Credential:
Phone: 346-816-9150