Provider Demographics
NPI:1164933958
Name:MEDICAL CLINIC AT THE RANCH PLLC
Entity Type:Organization
Organization Name:MEDICAL CLINIC AT THE RANCH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIJAYA
Authorized Official - Middle Name:L
Authorized Official - Last Name:DWIBHASHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-394-0093
Mailing Address - Street 1:PO BOX 723
Mailing Address - Street 2:
Mailing Address - City:FULSHEAR
Mailing Address - State:TX
Mailing Address - Zip Code:77441-0723
Mailing Address - Country:US
Mailing Address - Phone:281-394-0093
Mailing Address - Fax:281-371-0121
Practice Address - Street 1:9555 SPRING GREEN BLVD
Practice Address - Street 2:SUITE H
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-3462
Practice Address - Country:US
Practice Address - Phone:281-394-0093
Practice Address - Fax:281-371-0121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-19
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN3624207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty