Healthcare Provider Details

I. General information

NPI: 1679554844
Provider Name (Legal Business Name): SANGER AVENUE MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 06/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6614 SANGER AVE
WACO TX
76710-4253
US

IV. Provider business mailing address

6614 SANGER AVE
WACO TX
76710-4253
US

V. Phone/Fax

Practice location:
  • Phone: 254-752-2300
  • Fax: 254-752-9436
Mailing address:
  • Phone: 254-752-2300
  • Fax: 254-752-9436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberJ8840
License Number StateTX

VIII. Authorized Official

Name: DR. DOUGLAS L HORNER
Title or Position: CLINIC ADMINISTRATOR
Credential: PH.D.
Phone: 254-752-2300