=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558696187
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | METROCARE WELLNESS CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2009
-----------------------------------------------------
Last Update Date | 10/15/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11040 EAST FWY
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77029-1931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-763-4822
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11040 EAST FWY
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77029-1931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-763-4822
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING DIRECTOR
-----------------------------------------------------
Name | EGHOSA AIDEYAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-763-4822
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------