Provider Demographics
NPI:1164816021
Name:BROUSSARD, CLINTON
Entity Type:Individual
Prefix:MR
First Name:CLINTON
Middle Name:
Last Name:BROUSSARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4631 KNOTTYNOLD LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77053-1103
Mailing Address - Country:US
Mailing Address - Phone:832-461-9852
Mailing Address - Fax:713-433-1753
Practice Address - Street 1:4631 KNOTTYNOLD LN
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77053-1103
Practice Address - Country:US
Practice Address - Phone:832-461-9852
Practice Address - Fax:713-433-1753
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10168489343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)