Provider Demographics
NPI:1164403069
Name:CHOICE SOURCE THERAPEUTIC OF HOUSTON, TEXAS, L.L.C.
Entity Type:Organization
Organization Name:CHOICE SOURCE THERAPEUTIC OF HOUSTON, TEXAS, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED SIGNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:BORDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-225-5967
Mailing Address - Street 1:PO BOX 840688
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0688
Mailing Address - Country:US
Mailing Address - Phone:800-225-5967
Mailing Address - Fax:909-799-4364
Practice Address - Street 1:20333 STATE HIGHWAY 249
Practice Address - Street 2:SUITE 450
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070
Practice Address - Country:US
Practice Address - Phone:281-257-7900
Practice Address - Fax:281-257-7920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-08
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19617332B00000X, 333600000X, 3336H0001X
3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX580024OtherMEDICARE B (TRAILBLAZER)
OH2441423Medicaid
TXAH05OtherHEMO ASSISTANCE
AL009914034Medicaid
TX091576104Medicaid
OK100245870AMedicaid
ID806568400Medicaid
TX320199Medicaid
IN200422190Medicaid
TX320199OtherCHIP
TX091576105Medicaid
AL100560035Medicaid
AL009914034Medicaid