MEDICARE: SPACE CITY EMS 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	341600000X	Ambulance	800204	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	800204	OTHER	TX	PROVIDER STATE LICENSE

General Provider Information

NPI Number	:	1275692287
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPACE CITY EMS LLC

Provider Business Mailing Address
First Line	:	7999 HANSEN RD STE 308
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77061-3450
Country	:	US
Telephone Number	:	713-944-4667
Fax Number	:	713-946-4888

Provider Business Practice Location Address
First Line	:	7999 HANSEN RD STE 308
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77061-3450
Country	:	US
Telephone Number	:	713-944-4667
Fax Number	:	713-946-4888

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. MELISSA FONSECA
Credential	:
Telephone Number	:	713-944-4667

Provider Enumeration Date	:	12/06/2006
Last Update Date	:	08/22/2020

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Directions to “SPACE CITY EMS LLC ” Practice Location

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