MEDICARE: MR. CLINTON BROUSSARD

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	343900000X	Non-emergency Medical Transport (VAN)	10168489	TX

General Provider Information

NPI Number	:	1164816021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CLINTON BROUSSARD

Provider Business Mailing Address
First Line	:	4631 KNOTTYNOLD LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77053-1103
Country	:	US
Telephone Number	:	832-461-9852
Fax Number	:	713-433-1753

Provider Business Practice Location Address
First Line	:	4631 KNOTTYNOLD LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77053-1103
Country	:	US
Telephone Number	:	832-461-9852
Fax Number	:	713-433-1753

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2015
Last Update Date	:	03/27/2015

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Directions to “ MR. CLINTON BROUSSARD ” Practice Location

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