=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871596577
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MITZI STOREY CST
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2005
-----------------------------------------------------
Last Update Date | 06/30/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3333 BAYSHORE BLVD STE 200
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77504-1944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-944-5550
-----------------------------------------------------
Fax | 713-944-5618
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3333 BAYSHORE BLVD STE 200
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77504-1944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-944-5550
-----------------------------------------------------
Fax | 713-944-5618
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246ZS0410X
-----------------------------------------------------
Taxonomy Name | Surgical Technologist
-----------------------------------------------------
License Number | 93703
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------