Healthcare Provider Details

I. General information

NPI: 1528240074
Provider Name (Legal Business Name): MEDVAMC-HOUSTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2007
Last Update Date: 11/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17307 DANBURY BRIDGE DR.
HOUSTON TX
77095
US

IV. Provider business mailing address

2002 HOLCOME BLVD.
HOUSTON TX
77030
US

V. Phone/Fax

Practice location:
  • Phone: 936-522-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number253803
License Number StateTX

VIII. Authorized Official

Name: MS. CAROL ANN BECKWITH
Title or Position: STAFF NURSE
Credential: R.N.
Phone: 936-522-4000