=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831271188
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLEAR LAKE INTEGRATED HEALTH CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2006
-----------------------------------------------------
Last Update Date | 07/08/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7 PROFESSIONAL PARK DR
-----------------------------------------------------
City | WEBSTER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77598-4123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-338-1815
-----------------------------------------------------
Fax | 281-316-2539
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15514 CONIFER BAY CT
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-338-1815
-----------------------------------------------------
Fax | 281-316-2539
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | PUSHPA Y REDDY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 281-338-1815
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------