=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063879955
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LATIN CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2016
-----------------------------------------------------
Last Update Date | 01/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3961 S GESSNER RD
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77063-5135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-986-5007
-----------------------------------------------------
Fax | 832-986-5097
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3961 S GESSNER RD
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77063-5135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-986-5007
-----------------------------------------------------
Fax | 832-986-5097
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. JANET VICTORTES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-247-1994
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------