=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790185098
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KATY DME, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2014
-----------------------------------------------------
Last Update Date | 07/31/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 462 S MASON RD STE 400
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77450-2451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-693-5289
-----------------------------------------------------
Fax | 281-693-3111
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 462 S MASON RD STE 400
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77450-2451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-693-5289
-----------------------------------------------------
Fax | 281-693-3111
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | HECTOR UBALDO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 281-693-5289
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------