MEDICARE: CLINICA HISPANASALUD INTEGRAL

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	313M00000X	Nursing Facility/Intermediate Care Facility	J6641	TX

General Provider Information

NPI Number	:	1750716791
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLINICA HISPANASALUD INTEGRAL

Provider Business Mailing Address
First Line	:	737 W CAVALCADE ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77009-3048
Country	:	US
Telephone Number	:	832-831-6350
Fax Number	:	832-831-6351

Provider Business Practice Location Address
First Line	:	737 W CAVALCADE ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77009-3048
Country	:	US
Telephone Number	:	832-831-6350
Fax Number	:	832-831-6351

Authorized Official
Title or Position	:	DOCTOR
Name	:	DR. STANTONT CLARK PACKARD
Credential	:	MD
Telephone Number	:	832-831-6350

Provider Enumeration Date	:	09/10/2013
Last Update Date	:	09/10/2013

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