Healthcare Provider Details

I. General information

NPI: 1699572958
Provider Name (Legal Business Name): MEN'S DIVISION PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2025
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11511 FM 1960 STE 102
HUFFMAN TX
77336-2710
US

IV. Provider business mailing address

1514 LYNNVIEW DR
HOUSTON TX
77055-3428
US

V. Phone/Fax

Practice location:
  • Phone: 832-832-8570
  • Fax: 346-299-7263
Mailing address:
  • Phone: 281-900-0597
  • Fax: 346-299-7263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL ROACH
Title or Position: FNP-BC
Credential: PRESIDENT
Phone: 281-900-0597