Healthcare Provider Details

I. General information

NPI: 1689955601
Provider Name (Legal Business Name): IMPERIAL SURGICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2011
Last Update Date: 07/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 DETERING ST
HOUSTON TX
77007-7127
US

IV. Provider business mailing address

410 DETERING ST
HOUSTON TX
77007-7127
US

V. Phone/Fax

Practice location:
  • Phone: 903-826-3302
  • Fax:
Mailing address:
  • Phone: 903-826-3302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA06288TX
License Number StateTX

VIII. Authorized Official

Name: JOSHUA HUNTER GREENE
Title or Position: MANAGING MEMBER
Credential:
Phone: 903-826-3302