=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083332845
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NUROCOACH MEDICAL GROUP PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2022
-----------------------------------------------------
Last Update Date | 08/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 SOUTHWESTERN BLVD STE 200
-----------------------------------------------------
City | SUGAR LAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77478-3568
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-954-6876
-----------------------------------------------------
Fax | 855-859-6876
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 SOUTHWESTERN BLVD STE 200
-----------------------------------------------------
City | SUGAR LAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77478-3568
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-954-6876
-----------------------------------------------------
Fax | 855-859-6876
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | TACCARA ROSS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 225-803-7877
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------