Provider Demographics
NPI:1457839516
Name:PROVIDENCE CLEARLAKE SPECIALTY HOSPITAL LLC
Entity Type:Organization
Organization Name:PROVIDENCE CLEARLAKE SPECIALTY HOSPITAL LLC
Other - Org Name:CLEARLAKE SPECIALTY HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:ARIN
Authorized Official - Middle Name:
Authorized Official - Last Name:TIJERINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-453-7232
Mailing Address - Street 1:20320 NORTHWEST FWY STE 900
Mailing Address - Street 2:
Mailing Address - City:JERSEY VILLAGE
Mailing Address - State:TX
Mailing Address - Zip Code:77065-5620
Mailing Address - Country:US
Mailing Address - Phone:281-453-7232
Mailing Address - Fax:281-453-2203
Practice Address - Street 1:1351 CLEARLAKE CITY BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77062
Practice Address - Country:US
Practice Address - Phone:281-453-7232
Practice Address - Fax:281-453-2203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital