MEDICARE: HOUSTON ADVANCE MEDILINE CLINIC

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	261QM1300X	Multi-Specialty Clinic/Center		TX

General Provider Information

NPI Number	:	1508009309
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOUSTON ADVANCE MEDILINE CLINIC

Provider Business Mailing Address
First Line	:	6550 MAPLERIDGE ST STE 214
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77081-4647
Country	:	US
Telephone Number	:	713-669-0848
Fax Number	:	713-669-0648

Provider Business Practice Location Address
First Line	:	6550 MAPLERIDGE ST STE 214
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77081-4647
Country	:	US
Telephone Number	:	713-669-0848
Fax Number	:	713-669-0648

Authorized Official
Title or Position	:	CEO
Name	:	MR. EMMANUEL M ANUSIEM
Credential	:	OWNER
Telephone Number	:	713-669-0848

Provider Enumeration Date	:	04/09/2009
Last Update Date	:	04/09/2009

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