Healthcare Provider Details

I. General information

NPI: 1255567848
Provider Name (Legal Business Name): DOMINION MEDICAL HEALTHCARE SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2009
Last Update Date: 08/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 BISSONNET ST SUITE 130
HOUSTON TX
77074-3900
US

IV. Provider business mailing address

8300 BISSONNET ST SUITE 130
HOUSTON TX
77074-3900
US

V. Phone/Fax

Practice location:
  • Phone: 281-974-4400
  • Fax: 281-974-4386
Mailing address:
  • Phone: 281-974-4400
  • Fax: 281-974-4386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 03172
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: IRENONA WATSON
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 281-974-4400