Healthcare Provider Details

I. General information

NPI: 1528795150
Provider Name (Legal Business Name): LAKE HOUSTON INTERVENTIONAL PAIN PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2022
Last Update Date: 08/03/2022
Certification Date: 08/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7040 FM 1960 RD E
HUMBLE TX
77346-2704
US

IV. Provider business mailing address

7040 FM 1960 RD E
HUMBLE TX
77346-2704
US

V. Phone/Fax

Practice location:
  • Phone: 281-713-5556
  • Fax: 409-554-0921
Mailing address:
  • Phone: 281-713-5556
  • Fax: 409-554-0921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: CRAIG A CHARLESTON
Title or Position: AUTHORIZED OFFICIAL / MD
Credential: MD
Phone: 281-713-5556