Healthcare Provider Details

I. General information

NPI: 1922449370
Provider Name (Legal Business Name): LA PORTE MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2013
Last Update Date: 11/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 W FAIRMONT PKWY
LA PORTE TX
77571-6105
US

IV. Provider business mailing address

PO BOX 840795
DALLAS TX
75284-0795
US

V. Phone/Fax

Practice location:
  • Phone: 972-899-6666
  • Fax: 972-899-5954
Mailing address:
  • Phone: 972-899-6666
  • Fax: 972-899-5954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License Number160090
License Number StateTX

VIII. Authorized Official

Name: TIM FIELDING
Title or Position: CFO
Credential:
Phone: 972-899-6650