=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649493149
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIMO HEALTH AND INJURY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6601 HILLCROFT ST SUITE 100
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77081-4888
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-270-0077
-----------------------------------------------------
Fax | 713-270-0102
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6601 HILLCROFT ST SUITE 100
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77081-4888
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-270-0077
-----------------------------------------------------
Fax | 713-270-0102
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. JOHN WALLACE PARK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 713-270-0077
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | F006212
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------