=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104495027
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRO MEDICO ALMEDA, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2021
-----------------------------------------------------
Last Update Date | 06/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10150 ALMEDA GENOA RD
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77075-2435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-790-9990
-----------------------------------------------------
Fax | 713-790-9990
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10731 SKILLINGS RIDGE DR
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77075-1441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-340-9803
-----------------------------------------------------
Fax | 713-790-9990
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | MANUEL CORCHO ALONSO
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 713-340-9803
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------