Provider Demographics
NPI:1326555913
Name:BLUEBONNET PROCARE PLLC
Entity Type:Organization
Organization Name:BLUEBONNET PROCARE PLLC
Other - Org Name:GULF COAST INFUSION CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-679-0003
Mailing Address - Street 1:4660 SWEETWATER BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-3164
Mailing Address - Country:US
Mailing Address - Phone:713-679-0003
Mailing Address - Fax:832-218-2300
Practice Address - Street 1:4660 SWEETWATER BLVD STE 150
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-3164
Practice Address - Country:US
Practice Address - Phone:713-679-0003
Practice Address - Fax:832-218-2300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-04
Last Update Date:2021-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD5478208D00000X
208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD5478OtherLICENSE
TX3812463Medicaid