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NPI Code Detail

MEDICARE: IBEJI VILLAGE, LLC

MEDICARE: IBEJI VILLAGE, LLC
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
1174400000XSpecialist

General Provider Information

NPI Number : 1184317182
Entity Type Code : Organization
Provider Name (Legal Business Name) : IBEJI VILLAGE, LLC
Provider Business Mailing Address
First Line : 2950 S GESSNER RD STE 208
Second Line :
City : HOUSTON
State : TX
Zip : 77063-3774
Country : US
Telephone Number : 772-332-9885
Fax Number :
Provider Business Practice Location Address
First Line : 2950 S GESSNER RD STE 208
Second Line :
City : HOUSTON
State : TX
Zip : 77063-3774
Country : US
Telephone Number : 772-332-9885
Fax Number :
Authorized Official
Title or Position : OWNER
Name : DR. THALIA LAEL MICAH
Credential :
Telephone Number : 772-332-9885
Provider Enumeration Date : 05/26/2023
Last Update Date : 05/26/2023

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Directions to “IBEJI VILLAGE, LLC ” Practice Location

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