Healthcare Provider Details

I. General information

NPI: 1225518798
Provider Name (Legal Business Name): CLARE HORADAM PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2018
Last Update Date: 08/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 VILLAGE RD
PORT LAVACA TX
77979-2380
US

IV. Provider business mailing address

524 VILLAGE RD
PORT LAVACA TX
77979-2380
US

V. Phone/Fax

Practice location:
  • Phone: 361-552-3741
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number2089610
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: