=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962805036
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 1ST MEDCARE CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2014
-----------------------------------------------------
Last Update Date | 10/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2306 N ALEXANDER DR
-----------------------------------------------------
City | BAYTOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77520-3455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-877-3380
-----------------------------------------------------
Fax | 281-428-7247
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 505
-----------------------------------------------------
City | BELLAIRE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77402-0505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-877-3380
-----------------------------------------------------
Fax | 282-428-7247
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | BEN KODAE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 832-877-3380
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 132700000X
-----------------------------------------------------
Taxonomy Name | Dietary Manager
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207XX0005X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------