Provider Demographics
NPI:1063824829
Name:LA PROVIDENCE MEDICAL CENTER
Entity Type:Organization
Organization Name:LA PROVIDENCE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:DR
Authorized Official - First Name:IFEYINWA
Authorized Official - Middle Name:
Authorized Official - Last Name:ONWUDIWE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:713-909-3139
Mailing Address - Street 1:9644 COURT GLEN DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77099-2541
Mailing Address - Country:US
Mailing Address - Phone:713-909-3139
Mailing Address - Fax:713-909-6002
Practice Address - Street 1:9644 COURT GLEN DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77099-2541
Practice Address - Country:US
Practice Address - Phone:713-909-3139
Practice Address - Fax:713-909-6002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-28
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA201564208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty