Provider Demographics
NPI:1083202402
Name:SPACE CITY MEDICAL, LLC
Entity Type:Organization
Organization Name:SPACE CITY MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:832-549-6655
Mailing Address - Street 1:7401 GLEASON RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77016-2708
Mailing Address - Country:US
Mailing Address - Phone:832-549-6655
Mailing Address - Fax:
Practice Address - Street 1:7401 GLEASON RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77016-2708
Practice Address - Country:US
Practice Address - Phone:832-549-6655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-03
Last Update Date:2021-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty