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General NPI Number Information
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NPI Number | 1972642940
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Entity Type | Organization
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Legal Business Name | CLEAR LAKE NEURO DIAGNOSTIC CLINIC PLLC
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Dates
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Enumeration Date | 02/06/2007
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Last Update Date | 03/04/2011
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Provider Practice Location Address
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Address Line | 380 E MEDICAL CENTER BLVD
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City | WEBSTER
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State | TX
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Zip | 77598-4321
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Country | US
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Telephone | 281-332-6949
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Fax | 281-332-6965
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Provider Business Mailing Address
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Address Line | 380 E MEDICAL CENTER BLVD
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City | WEBSTER
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State | TX
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Zip | 77598-4321
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Country | US
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Telephone | 281-332-6949
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Fax | 281-332-6965
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Authorized Official
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Title or Position | OFFICER
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Name | WILLA MARIE LEBAS
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Credential | M.D.
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Telephone | 281-332-6949
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | J9590
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License Number State | TX
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