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General NPI Number Information
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NPI Number | 1114227303
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Entity Type | Organization
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Legal Business Name | SOUTH MAIN MEDICAL CLINIC
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Dates
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Enumeration Date | 10/22/2010
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Last Update Date | 10/22/2010
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Provider Practice Location Address
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Address Line | 10021 S MAIN ST SUITE B3
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City | HOUSTON
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State | TX
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Zip | 77025-5224
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Country | US
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Telephone | 713-668-1166
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Fax | 713-668-8159
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Provider Business Mailing Address
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Address Line | 10021 S MAIN ST SUITE B3
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City | HOUSTON
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State | TX
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Zip | 77025-5224
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Country | US
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Telephone | 713-668-1166
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Fax | 713-668-8159
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. PETER WANGURI
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Credential |
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Telephone | 713-668-1166
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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