Provider Demographics
NPI:1457645087
Name:VALLEY MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:VALLEY MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:OSAGIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-877-0187
Mailing Address - Street 1:17567 IMPERIAL VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77060-6102
Mailing Address - Country:US
Mailing Address - Phone:281-877-0187
Mailing Address - Fax:281-877-0189
Practice Address - Street 1:17567 IMPERIAL VALLEY DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77060-6102
Practice Address - Country:US
Practice Address - Phone:281-877-0187
Practice Address - Fax:281-877-0189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-31
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB140907OtherMEDICARE PTAN