Healthcare Provider Details

I. General information

NPI: 1982862587
Provider Name (Legal Business Name): KL MODERN SPINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2008
Last Update Date: 04/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16659 SOUTHWEST FWY SUITE 151
SUGAR LAND TX
77479-2375
US

IV. Provider business mailing address

16659 SOUTHWEST FWY SUITE 151
SUGAR LAND TX
77479-2375
US

V. Phone/Fax

Practice location:
  • Phone: 713-774-6337
  • Fax: 281-313-7747
Mailing address:
  • Phone: 713-774-6337
  • Fax: 281-313-7747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DANIEL DOMINGUEZ
Title or Position: CEO
Credential:
Phone: 713-774-6337