MEDICARE: 610 MEDICAL CLINIC INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1104090984
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	610 MEDICAL CLINIC INC

Provider Business Mailing Address
First Line	:	1919 NORTH LOOP W STE 299
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77008-1368
Country	:	US
Telephone Number	:	281-853-6653
Fax Number	:	713-869-9470

Provider Business Practice Location Address
First Line	:	1919 NORTH LOOP W STE 299
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77008-1368
Country	:	US
Telephone Number	:	281-853-6653
Fax Number	:	713-869-9470

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. T J BOYCE
Credential	:
Telephone Number	:	281-853-6653

Provider Enumeration Date	:	04/14/2008
Last Update Date	:	04/14/2008

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