=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558485615
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. JOHNS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6410 FANNIN ST SUITE 1460
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77030-3000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-988-8860
-----------------------------------------------------
Fax | 713-988-8861
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 981095
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77098-8095
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-988-8860
-----------------------------------------------------
Fax | 713-988-8861
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | DR. SAMUEL CHEN
-----------------------------------------------------
Credential | MD, PH. D. MPH
-----------------------------------------------------
Telephone | 713-988-8860
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | K3125
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------