MEDICARE: VICKIE CLINE OPA-C, LSA, SA-C

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	246ZS0410X	Surgical Technologist	LSA: SA00167	TX
2	363AS0400X	Surgical Physician Assistant

General Provider Information

NPI Number	:	1700876919
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICKIE CLINE OPA-C, LSA, SA-C

Provider Business Mailing Address
First Line	:	2317 COBBLECREEK DR
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77384-3703
Country	:	US
Telephone Number	:	281-541-8872
Fax Number	:	331-625-7932

Provider Business Practice Location Address
First Line	:	2317 COBBLECREEK DR
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77384-3703
Country	:	US
Telephone Number	:	281-541-8872
Fax Number	:	331-625-7932

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/27/2005
Last Update Date	:	06/21/2017

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