=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679270623
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAVANA MEDICAL GROUP CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2023
-----------------------------------------------------
Last Update Date | 03/31/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 715 TELEPHONE RD
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77023-3117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-871-4777
-----------------------------------------------------
Fax | 832-871-4776
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 715 TELEPHONE RD
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77023-3117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-871-4777
-----------------------------------------------------
Fax | 832-871-4776
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DR. NORBE LUIS BASULTO BARCELAY
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 786-556-8819
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------