=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215353495
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACCUCARE HEALTH SYSTEMS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2014
-----------------------------------------------------
Last Update Date | 03/11/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1931 HUMBLE PLACE DR STE 207
-----------------------------------------------------
City | HUMBLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77338-5255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-249-0997
-----------------------------------------------------
Fax | 281-318-7183
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12634 BLACKSTONE RIVER DR
-----------------------------------------------------
City | HUMBLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77346-3540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-249-0997
-----------------------------------------------------
Fax | 281-318-7183
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR/OWNER
-----------------------------------------------------
Name | MRS. TINA RENEE DOMIO
-----------------------------------------------------
Credential | LVN
-----------------------------------------------------
Telephone | 832-249-0997
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------