=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578795993
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLEAR LAKE COMPLETE CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2009
-----------------------------------------------------
Last Update Date | 05/04/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 907 EL DORADO BLVD STE B
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77062-4044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-480-9931
-----------------------------------------------------
Fax | 281-402-1980
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 907 EL DORADO BLVD STE B
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77062-4044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-480-9931
-----------------------------------------------------
Fax | 281-402-1980
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. MICHAEL T MARTIN
-----------------------------------------------------
Credential | D.C
-----------------------------------------------------
Telephone | 281-488-2291
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------