Provider Demographics
NPI:1164726956
Name:290 MANGUM HEALTHCARE LLC
Entity Type:Organization
Organization Name:290 MANGUM HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TABARE
Authorized Official - Middle Name:D
Authorized Official - Last Name:TABAR
Authorized Official - Suffix:
Authorized Official - Credentials:P A
Authorized Official - Phone:713-682-2212
Mailing Address - Street 1:5005 W 34TH ST
Mailing Address - Street 2:SUITE 102C
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77092-4200
Mailing Address - Country:US
Mailing Address - Phone:713-682-2212
Mailing Address - Fax:713-682-9997
Practice Address - Street 1:5005 W 34TH ST
Practice Address - Street 2:SUITE 102C
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77092-4200
Practice Address - Country:US
Practice Address - Phone:713-682-2212
Practice Address - Fax:713-682-9997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-07
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01537207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty