Healthcare Provider Details

I. General information

NPI: 1255977583
Provider Name (Legal Business Name): REHOBOTH MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2019
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25231 ROESNER LN
KATY TX
77494-5537
US

IV. Provider business mailing address

25231 ROESNER LN
KATY TX
77494-5537
US

V. Phone/Fax

Practice location:
  • Phone: 281-506-7412
  • Fax: 281-530-2882
Mailing address:
  • Phone: 281-506-7412
  • Fax: 281-530-2882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: STELLA GRACE IMMANUEL
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 281-506-7412