=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114304748
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIETUS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2015
-----------------------------------------------------
Last Update Date | 05/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5847 SAN FELIPE ST STE 1700
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77057-3073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-407-5151
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5847 SAN FELIPE PLAZA,STE 1700
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-407-5151
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | TORY CRAWFORD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 832-407-5151
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------