=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811356769
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOTERION KINGDOM PERSONAL AND FAMILY MANAGEMENT CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2016
-----------------------------------------------------
Last Update Date | 02/21/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9321 EDGEBROOK ST STE C
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77075-1249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-814-8301
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7401 GULF FWY
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77017-1580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BOARD DIRECTOR
-----------------------------------------------------
Name | MR. SAMUEL JOHNSON
-----------------------------------------------------
Credential | MBA,CPA
-----------------------------------------------------
Telephone | 281-882-9036
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------