Provider Demographics
NPI:1346647203
Name:CCLINIC ALLIANCE, PLLC
Entity Type:Organization
Organization Name:CCLINIC ALLIANCE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF BUSINESS OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:REGGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ABRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-730-4766
Mailing Address - Street 1:8111 SOUTHWEST FREEWAY
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77074-1705
Mailing Address - Country:US
Mailing Address - Phone:713-730-4800
Mailing Address - Fax:
Practice Address - Street 1:8111 SOUTHWEST FWY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-1705
Practice Address - Country:US
Practice Address - Phone:713-730-4800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA