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General NPI Number Information
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NPI Number | 1588964613
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Entity Type | Organization
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Legal Business Name | SOUTHWEST SURGICAL ENT CLINIC INC
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Dates
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Enumeration Date | 10/22/2010
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Last Update Date | 10/22/2010
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Provider Practice Location Address
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Address Line | 4140 SOUTHWEST FWY STE 510
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City | HOUSTON
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State | TX
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Zip | 77027-7319
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Country | US
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Telephone | 713-621-2558
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Fax |
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Provider Business Mailing Address
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Address Line | 4140 SOUTHWEST FWY STE 510
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City | HOUSTON
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State | TX
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Zip | 77027-7319
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/BUSINESS DEVELOPMENT
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Name | OMAR FUSTOK
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Credential |
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Telephone | 832-419-2268
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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