=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245647072
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPRING SHADOWS MEDICAL CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2014
-----------------------------------------------------
Last Update Date | 08/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2549 GESSNER RD
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77080-3801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-538-9431
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2549 GESSNER RD
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77080-3801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-538-9431
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. RUBEENA AYESHA
-----------------------------------------------------
Credential | N.P.
-----------------------------------------------------
Telephone | 917-538-9431
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 827700
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------