=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699377945
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE MINDCARE CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2020
-----------------------------------------------------
Last Update Date | 11/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 333 WEST LOOP N STE 320
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77024-7767
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-283-2878
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 333 WEST LOOP N STE 320
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77024-7767
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-283-2878
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. SHEROD BURNETT COLEMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 713-283-2878
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------