MEDICARE: SDLDM, INC DBA PASSPORT HEALTH HOUSTON

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	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1134545072
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SDLDM, INC DBA PASSPORT HEALTH HOUSTON

Provider Business Mailing Address
First Line	:	9601 KATY FWY STE 315
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77024-1360
Country	:	US
Telephone Number	:	713-467-6575
Fax Number	:	713-467-6881

Provider Business Practice Location Address
First Line	:	9601 KATY FWY
Second Line	:	SUITE 315
City	:	HOUSTON
State	:	TX
Zip	:	77024-1342
Country	:	US
Telephone Number	:	713-467-6575
Fax Number	:	713-467-6881

Authorized Official
Title or Position	:	OWNER/EXECUTIVE DIRECTOR
Name	:	MRS. DEBORAH LINDSAY MEDELLIN
Credential	:
Telephone Number	:	713-467-6575

Provider Enumeration Date	:	03/17/2014
Last Update Date	:	03/17/2014

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