MEDICARE: I 45 MEDICAL CLINIC, 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
1	208D00000X	General Practice Physician		TX

General Provider Information

NPI Number	:	1235450644
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	I 45 MEDICAL CLINIC, LLC.

Provider Business Mailing Address
First Line	:	4141 NORTH FWY
Second Line	:	SUITE # 100
City	:	HOUSTON
State	:	TX
Zip	:	77022-4208
Country	:	US
Telephone Number	:	713-699-0900
Fax Number	:	713-699-0903

Provider Business Practice Location Address
First Line	:	4141 NORTH FWY
Second Line	:	SUITE # 100
City	:	HOUSTON
State	:	TX
Zip	:	77022-4208
Country	:	US
Telephone Number	:	713-699-0900
Fax Number	:	713-699-0903

Authorized Official
Title or Position	:	OWNER
Name	:	MR. ANGELO SOTO
Credential	:
Telephone Number	:	713-699-0900

Provider Enumeration Date	:	06/21/2010
Last Update Date	:	06/21/2010

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