=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730660879
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEALY URGENT CARE CENTER P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2018
-----------------------------------------------------
Last Update Date | 08/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1036 N CIRCLE DR STE 101
-----------------------------------------------------
City | SEALY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77474-3336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-627-6224
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1036 N CIRCLE DR STE 101
-----------------------------------------------------
City | SEALY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77474-3336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-627-6224
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KANNAPPAN KRISHNASWAMY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 281-701-9576
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------