MEDICARE: CTB ULTIMATE HEALTHCARE FACILITY

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	302R00000X	Health Maintenance Organization

General Provider Information

NPI Number	:	1689974594
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CTB ULTIMATE HEALTHCARE FACILITY

Provider Business Mailing Address
First Line	:	301 WELLS FARGO DR STE C6
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77090-4060
Country	:	US
Telephone Number	:	281-433-9059
Fax Number	:	281-651-6551

Provider Business Practice Location Address
First Line	:	301 WELLS FARGO DR STE C6
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77090-4060
Country	:	US
Telephone Number	:	281-433-9059
Fax Number	:	281-651-6551

Authorized Official
Title or Position	:	OWNER
Name	:	THERESA F WHITE-BROOKS
Credential	:
Telephone Number	:	281-433-9059

Provider Enumeration Date	:	10/26/2010
Last Update Date	:	10/26/2010

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