MEDICARE: MOTHERLAND, INC.

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	261QF0400X	Federally Qualified Health Center (FQHC)	540680	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00Z744	OTHER	TX	MEDICARE PART B
2	671926	OTHER	TX	MEDICARE PART A

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912298407
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOTHERLAND, INC.

Provider Business Mailing Address
First Line	:	4040 YALE ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77018-5928
Country	:	US
Telephone Number	:	713-290-0001
Fax Number	:	713-290-0023

Provider Business Practice Location Address
First Line	:	4040 YALE ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77018-5928
Country	:	US
Telephone Number	:	713-290-0001
Fax Number	:	713-290-0023

Authorized Official
Title or Position	:	CEO/FOUNDER
Name	:	MR. VICTOR NDANDO-NGOO
Credential	:
Telephone Number	:	713-290-0001

Provider Enumeration Date	:	05/02/2011
Last Update Date	:	05/02/2011

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Directions to “MOTHERLAND, INC. ” Practice Location

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