MEDICARE: HOMESTEAD 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	173000000X	Legal Medicine

General Provider Information

NPI Number	:	1467736512
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOMESTEAD MEDICAL CLINIC, LLC

Provider Business Mailing Address
First Line	:	8213 HOMESTEAD RD
Second Line	:	SUITE A
City	:	HOUSTON
State	:	TX
Zip	:	77028-2152
Country	:	US
Telephone Number	:	281-974-1147
Fax Number	:

Provider Business Practice Location Address
First Line	:	8213 HOMESTEAD RD
Second Line	:	SUITE A
City	:	HOUSTON
State	:	TX
Zip	:	77028-2152
Country	:	US
Telephone Number	:	281-974-1147
Fax Number	:

Authorized Official
Title or Position	:	CEO/OWNER
Name	:	TRINA L DEBOSE
Credential	:
Telephone Number	:	281-974-1147

Provider Enumeration Date	:	10/07/2011
Last Update Date	:	10/08/2011

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