MEDICARE: SHALOM MOBILE HEALTH MINISTRY

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	363AM0700X	Medical Physician Assistant	PA01477	TX

General Provider Information

NPI Number	:	1134437189
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHALOM MOBILE HEALTH MINISTRY

Provider Business Mailing Address
First Line	:	8121 BROADWAY ST
Second Line	:	STE. 103
City	:	HOUSTON
State	:	TX
Zip	:	77061-1340
Country	:	US
Telephone Number	:	713-900-2750
Fax Number	:	713-900-2751

Provider Business Practice Location Address
First Line	:	8121 BROADWAY ST
Second Line	:	STE. 103
City	:	HOUSTON
State	:	TX
Zip	:	77061-1340
Country	:	US
Telephone Number	:	713-900-2750
Fax Number	:	713-900-2751

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MRS. MONICA KING
Credential	:
Telephone Number	:	713-900-2750

Provider Enumeration Date	:	09/23/2010
Last Update Date	:	03/07/2012

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