Provider Demographics
NPI:1205025772
Name:INTERSTATE CLINIC
Entity Type:Organization
Organization Name:INTERSTATE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:VAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-598-7633
Mailing Address - Street 1:181 W DYNA DR
Mailing Address - Street 2:SUITE G
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77037-1102
Mailing Address - Country:US
Mailing Address - Phone:281-598-7633
Mailing Address - Fax:281-598-7635
Practice Address - Street 1:181 W DYNA DR
Practice Address - Street 2:SUITE G
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77037-1102
Practice Address - Country:US
Practice Address - Phone:281-598-7633
Practice Address - Fax:281-598-7635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty