MEDICARE: TELACLINIC

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	207QA0505X	Adult Medicine Physician	L8734	TX

General Provider Information

NPI Number	:	1114244704
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TELACLINIC

Provider Business Mailing Address
First Line	:	9337B KATY FWY
Second Line	:	131
City	:	HOUSTON
State	:	TX
Zip	:	77024-1515
Country	:	US
Telephone Number	:	281-633-0148
Fax Number	:

Provider Business Practice Location Address
First Line	:	117 LANE DR
Second Line	:	SUITE 2
City	:	ROSENBERG
State	:	TX
Zip	:	77471-2200
Country	:	US
Telephone Number	:	281-633-0148
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. WALTER HOLMSTEN
Credential	:
Telephone Number	:	281-633-0148

Provider Enumeration Date	:	04/23/2010
Last Update Date	:	04/23/2010

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Directions to “TELACLINIC ” Practice Location

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