=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508015835
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDSTAR PRIMARY CARE CLINIC P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2008
-----------------------------------------------------
Last Update Date | 12/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14629 BEECHNUT ST
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77083-4436
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-933-4447
-----------------------------------------------------
Fax | 281-933-5557
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14629 BEECHNUT ST
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77083-4436
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-933-4447
-----------------------------------------------------
Fax | 281-933-5557
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. RACHEL CHUNDENU KIENTCHA - TITA
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 832-545-4614
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | M9410
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------