MEDICARE: CLINICA FAMILIAR UNIVERSAL 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	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1922342112
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLINICA FAMILIAR UNIVERSAL LLC

Provider Business Mailing Address
First Line	:	2506 W MOUNT HOUSTON RD STE H-1
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77038-3518
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2506 W MOUNT HOUSTON RD STE H-1
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77038-3518
Country	:	US
Telephone Number	:	281-847-1133
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	ROLANDO GONGAR
Credential	:
Telephone Number	:	281-847-1133

Provider Enumeration Date	:	11/12/2012
Last Update Date	:	11/12/2012

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