=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104080878
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WESTCO MEDICAL, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2008
-----------------------------------------------------
Last Update Date | 07/11/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18955 N MEMORIAL DR STE 490
-----------------------------------------------------
City | HUMBLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77338-4399
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-589-4863
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1442 KINGWOOD DR # 230
-----------------------------------------------------
City | KINGWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77339-3040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-589-4863
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYCISIAN
-----------------------------------------------------
Name | MR. LORIN FRED BUSSELBERG
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 713-589-4863
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302F00000X
-----------------------------------------------------
Taxonomy Name | Exclusive Provider Organization
-----------------------------------------------------
License Number | L7675
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------