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General NPI Number Information
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NPI Number | 1881649747
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Entity Type | Organization
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Legal Business Name | BRAZOSPORT COMMUNITY MEDICAL CLINIC
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Dates
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Enumeration Date | 05/22/2006
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Last Update Date | 05/04/2015
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Provider Practice Location Address
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Address Line | 606 N GULF BLVD
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City | FREEPORT
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State | TX
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Zip | 77541-3902
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Country | US
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Telephone | 979-871-9453
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Fax | 979-871-9429
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Provider Business Mailing Address
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Address Line | 606 N GULF BLVD
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City | FREEPORT
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State | TX
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Zip | 77541-3902
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Country | US
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Telephone | 979-871-9453
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Fax | 979-871-9429
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Authorized Official
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Title or Position | CEO/PA
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Name | MR. INYANG E WILSON
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Credential | PA
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Telephone | 979-871-9453
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | PA00933
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License Number State | TX
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