=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366737678
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STUART STRACK ATP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2011
-----------------------------------------------------
Last Update Date | 06/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4401 S PINEMONT DR SUITE 216
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77041-9327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-835-3389
-----------------------------------------------------
Fax | 866-963-4539
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3206 S NOLAN CT
-----------------------------------------------------
City | PEARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77584-6676
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-409-2035
-----------------------------------------------------
Fax | 866-375-4185
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 247200000X
-----------------------------------------------------
Taxonomy Name | Other Technician
-----------------------------------------------------
License Number | ATP 4534
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------