=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104296441
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TEXAKANA EP PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2015
-----------------------------------------------------
Last Update Date | 09/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4646 COWHORN CREEK RD.
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-660-0555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6030 S. RICE AVE. SUITE C
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77081
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-660-0555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | TOM VO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 713-660-0557
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0002X
-----------------------------------------------------
Taxonomy Name | Emergency Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207PE0004X
-----------------------------------------------------
Taxonomy Name | Emergency Medical Services (Emergency Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------