=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710621792
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPLETE MEDICAL CARE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2022
-----------------------------------------------------
Last Update Date | 04/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3480 FANNIN ST STE B
-----------------------------------------------------
City | BEAUMONT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77701-3804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-832-6129
-----------------------------------------------------
Fax | 409-860-8150
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 20025
-----------------------------------------------------
City | BEAUMONT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77720-0025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-454-8773
-----------------------------------------------------
Fax | 409-860-8150
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FAMILY NURSE PRACTITIONER
-----------------------------------------------------
Name | MRS. TARA DIONNE OWENS
-----------------------------------------------------
Credential | FNP-C
-----------------------------------------------------
Telephone | 409-832-6129
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------