=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699227264
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY HEP C CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2016
-----------------------------------------------------
Last Update Date | 10/31/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7700 MAIN ST 400
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77030-4456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-831-7770
-----------------------------------------------------
Fax | 713-661-4828
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7700 MAIN ST 400
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77030-4456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-831-7770
-----------------------------------------------------
Fax | 713-661-4828
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. LEONARDO A PALAU
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 832-831-7770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number | K3377
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------