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General NPI Number Information
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NPI Number | 1902205321
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Entity Type | Organization
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Legal Business Name | PURE SURGICAL ASSISTANT
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Dates
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Enumeration Date | 08/21/2014
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Last Update Date | 09/10/2014
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Provider Practice Location Address
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Address Line | 475 BENDWOOD DR
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City | HOUSTON
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State | TX
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Zip | 77024-8813
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Country | US
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Telephone | 281-409-3854
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Fax | 832-201-7900
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Provider Business Mailing Address
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Address Line | PO BOX 79576
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City | HOUSTON
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State | TX
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Zip | 77279-9576
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Country | US
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Telephone | 713-234-0081
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Fax | 832-201-7900
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Authorized Official
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Title or Position | MANAGER
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Name | MS. QIJUN SONG
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Credential | LSA, SA-C
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Telephone | 713-234-0081
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | SA00504
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License Number State | TX
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