Provider Demographics
NPI:1447571344
Name:SPADE CHRIPORACTIC PHYSICAL MEDICINE & DIAGNOSTIC CLINIC
Entity Type:Organization
Organization Name:SPADE CHRIPORACTIC PHYSICAL MEDICINE & DIAGNOSTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LLORD
Authorized Official - Middle Name:OBINNA
Authorized Official - Last Name:NWOSU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-777-1734
Mailing Address - Street 1:9207 CLUB CREEK
Mailing Address - Street 2:SUITE 111
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77036-7745
Mailing Address - Country:US
Mailing Address - Phone:713-777-1734
Mailing Address - Fax:
Practice Address - Street 1:9207 COUNTRY CREEK DR
Practice Address - Street 2:SUITE 111
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77036-7714
Practice Address - Country:US
Practice Address - Phone:713-777-1734
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-15
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXNAMedicaid