MEDICARE: INCOGNITO SPA 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	2083B0002X	Obesity Medicine (Preventive Medicine) Physician
2	2083P0901X	Public Health & General Preventive Medicine Physician

General Provider Information

NPI Number	:	1710655139
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INCOGNITO SPA CLINIC LLC

Provider Business Mailing Address
First Line	:	2201 ARBOR ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77004-6026
Country	:	US
Telephone Number	:	833-430-4807
Fax Number	:

Provider Business Practice Location Address
First Line	:	2201 ARBOR ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77004-6026
Country	:	US
Telephone Number	:	833-430-4807
Fax Number	:	833-430-4807

Authorized Official
Title or Position	:	OWNER
Name	:	LATASHA KRAUTH
Credential	:
Telephone Number	:	346-816-9150

Provider Enumeration Date	:	08/31/2021
Last Update Date	:	08/31/2021

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