Provider Demographics
NPI:1083683098
Name:ORANGE FAMILY CLINIC
Entity Type:Organization
Organization Name:ORANGE FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICK
Authorized Official - Middle Name:
Authorized Official - Last Name:POMONIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:409-882-0995
Mailing Address - Street 1:PO BOX 54655
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70154-4655
Mailing Address - Country:US
Mailing Address - Phone:409-882-0995
Mailing Address - Fax:409-883-4440
Practice Address - Street 1:3306 RIDGEMONT DR
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:TX
Practice Address - Zip Code:77630-4236
Practice Address - Country:US
Practice Address - Phone:409-882-0995
Practice Address - Fax:409-883-4440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2009-11-05
Deactivation Date:2009-03-02
Deactivation Code:
Reactivation Date:2009-05-21
Provider Licenses
StateLicense IDTaxonomies
TXH0730174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45D0973723OtherCLIA CERTIFICATE
TX00A18HMedicare PIN