=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043233273
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FE FAMILY CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2006
-----------------------------------------------------
Last Update Date | 08/09/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8305 N. LA HOMA BLVD. SUITE # B
-----------------------------------------------------
City | MISSION
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78574
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-581-0401
-----------------------------------------------------
Fax | 956-581-0654
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3360
-----------------------------------------------------
City | MISSION
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78573-0057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-581-0401
-----------------------------------------------------
Fax | 956-581-0654
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN ASSISTANT
-----------------------------------------------------
Name | MR. JOSEPH UNUIGBOJE EROMOSELE
-----------------------------------------------------
Credential | P. A.,
-----------------------------------------------------
Telephone | 956-581-0401
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------