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General NPI Number Information
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NPI Number | 1598347890
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Entity Type | Organization
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Legal Business Name | MDA DIVERSIFIED ENTERPRISES CORP
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Dates
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Enumeration Date | 04/26/2021
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Last Update Date | 04/26/2021
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Provider Practice Location Address
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Address Line | 23527 FM 1314 RD STE E
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City | PORTER
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State | TX
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Zip | 77365-3724
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Country | US
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Telephone | 281-381-6190
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Fax |
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Provider Business Mailing Address
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Address Line | 21013 OLD SORTERS RD STE E
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City | PORTER
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State | TX
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Zip | 77365-7083
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Country | US
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Telephone | 281-381-6190
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Fax |
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Authorized Official
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Title or Position | CREDENTIAL/BILLER
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Name | BETTY BROWN
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Credential |
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Telephone | 281-556-1298
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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