Provider Demographics
NPI:1174864722
Name:DAYSTAR FAMILY MEDICAL CLINIC, INC
Entity Type:Organization
Organization Name:DAYSTAR FAMILY MEDICAL CLINIC, INC
Other - Org Name:DAYSTAR FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FAMILY NURSE PRACTITONER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSELINE
Authorized Official - Middle Name:OLUCHI
Authorized Official - Last Name:OKORO
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP-C
Authorized Official - Phone:281-396-4120
Mailing Address - Street 1:24603 LAKE PATH CIR
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77493-2716
Mailing Address - Country:US
Mailing Address - Phone:281-396-4120
Mailing Address - Fax:
Practice Address - Street 1:24603 LAKE PATH CIR
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77493-2716
Practice Address - Country:US
Practice Address - Phone:281-396-4120
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care