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General NPI Number Information
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NPI Number | 1053929430
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Entity Type | Organization
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Legal Business Name | EXECUTIVE SOLE PODIATRY, PLLC
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Dates
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Enumeration Date | 07/21/2020
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Last Update Date | 05/06/2021
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Provider Practice Location Address
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Address Line | 5373 W ALABAMA ST STE 204
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City | HOUSTON
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State | TX
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Zip | 77056-5923
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Country | US
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Telephone | 866-925-5662
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Fax | 866-925-5662
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Provider Business Mailing Address
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Address Line | 6445 FM 1463 RD STE 160-213
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City | KATY
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State | TX
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Zip | 77494-4027
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Country | US
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Telephone | 866-925-5662
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Fax |
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Authorized Official
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Title or Position | PODIATRIST
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Name | DR. ANETRA SHARICE MIRANDA
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Credential | DPM
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Telephone | 866-925-5662
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP1100X
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Taxonomy Name | Podiatric Clinic/Center
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License Number |
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License Number State |
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