Healthcare Provider Details

I. General information

NPI: 1235512682
Provider Name (Legal Business Name): PURPLE GATOR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2015
Last Update Date: 10/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17115 RED OAK DR SUITE 218
HOUSTON TX
77090-2641
US

IV. Provider business mailing address

17115 RED OAK DR SUITE 218
HOUSTON TX
77090-2641
US

V. Phone/Fax

Practice location:
  • Phone: 832-930-0362
  • Fax: 832-779-4362
Mailing address:
  • Phone: 832-930-0362
  • Fax: 830-779-4362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2006
License Number StateTX

VIII. Authorized Official

Name: DR. BRIAN SELBST
Title or Position: MEMBER
Credential:
Phone: 832-930-0362