=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891301438
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIMARY CARE OF HOUSTON PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2020
-----------------------------------------------------
Last Update Date | 09/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19255 PARK ROW STE 204B
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77084-7310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-829-3860
-----------------------------------------------------
Fax | 281-829-3861
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19255 PARK ROW STE 204
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77084-7310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-829-3860
-----------------------------------------------------
Fax | 281-829-3861
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | PAT LICHT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 713-962-4960
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------