MEDICARE: CHOICE SOURCE THERAPEUTIC OF HOUSTON TEXAS 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	3336M0002X	Mail Order Pharmacy

General Provider Information

NPI Number	:	1982866075
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHOICE SOURCE THERAPEUTIC OF HOUSTON TEXAS LLC

Provider Business Mailing Address
First Line	:	PO BOX 840688
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-0688
Country	:	US
Telephone Number	:	800-225-5967
Fax Number	:	909-799-4364

Provider Business Practice Location Address
First Line	:	20333 STATE HIGHWAY 249 STE 450
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77070-2643
Country	:	US
Telephone Number	:	281-257-7900
Fax Number	:	281-257-7920

Authorized Official
Title or Position	:	AUTHORIZED SIGNER
Name	:	MR. DAVID WILLIAM BORDER
Credential	:
Telephone Number	:	800-225-5967

Provider Enumeration Date	:	06/30/2008
Last Update Date	:	06/30/2008

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