=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104636711
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STATEN CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2025
-----------------------------------------------------
Last Update Date | 01/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6516 NEW RD
-----------------------------------------------------
City | NORTH ZULCH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77872-6337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-740-2405
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6516 NEW RD
-----------------------------------------------------
City | NORTH ZULCH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77872-6337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-740-2405
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DAVID STATEN
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 281-740-2405
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------