Healthcare Provider Details

I. General information

NPI: 1356553861
Provider Name (Legal Business Name): FORUM P JHONSA LOTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

REGENCY VILLAGE 409 GREEN ST.
WEBSTER TX
77598
US

IV. Provider business mailing address

403 ELDER GROVE COURT
PEARLAND TX
77584
US

V. Phone/Fax

Practice location:
  • Phone: 281-332-4738
  • Fax:
Mailing address:
  • Phone: 713-436-9245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number208993
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: