=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245804293
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLINICA HISPANA SALUD Y ESPERANZA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2021
-----------------------------------------------------
Last Update Date | 05/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8200 WILCREST DR STE 20
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77072-4338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 346-570-2594
-----------------------------------------------------
Fax | 346-246-3777
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2319 BLUE REEF DR
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77449-4798
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANA DELIA LOPEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 346-570-2594
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------