Healthcare Provider Details

I. General information

NPI: 1245117878
Provider Name (Legal Business Name): THIRD COAST IOM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2025
Last Update Date: 08/18/2025
Certification Date: 08/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 HAVEN SHORE LN
SUGAR LAND TX
77479-3748
US

IV. Provider business mailing address

63 HAVEN SHORE LN
SUGAR LAND TX
77479-3748
US

V. Phone/Fax

Practice location:
  • Phone: 832-334-1436
  • Fax:
Mailing address:
  • Phone: 832-334-1436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARQUIS HOGUE
Title or Position: OWNER
Credential:
Phone: 832-334-1436