Provider Demographics
NPI:1275786592
Name:CLEAR LAKE SPINE CENTER, LLC
Entity Type:Organization
Organization Name:CLEAR LAKE SPINE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPINE
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:C
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:713-807-7721
Mailing Address - Street 1:2616 MASON ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77006-3116
Mailing Address - Country:US
Mailing Address - Phone:713-807-7721
Mailing Address - Fax:281-333-1303
Practice Address - Street 1:3750 MEDICAL PARK DR
Practice Address - Street 2:SUITE 300
Practice Address - City:DICKINSON
Practice Address - State:TX
Practice Address - Zip Code:77539
Practice Address - Country:US
Practice Address - Phone:713-357-4400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-30
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008379261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical