Healthcare Provider Details

I. General information

NPI: 1780392779
Provider Name (Legal Business Name): BRENT SPILLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2022
Last Update Date: 11/09/2022
Certification Date: 11/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14857 SOUTHWEST FWY
SUGAR LAND TX
77478-5016
US

IV. Provider business mailing address

711 REAGAN PARK CT
ROSENBERG TX
77469-2969
US

V. Phone/Fax

Practice location:
  • Phone: 281-242-8900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number2143963
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: