Provider Demographics
NPI:1497279616
Name:CLINICA PROVIDENCIA,LLC
Entity Type:Organization
Organization Name:CLINICA PROVIDENCIA,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ALVAREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-649-2347
Mailing Address - Street 1:6829B NAVIGATION BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77011-1452
Mailing Address - Country:US
Mailing Address - Phone:832-649-2347
Mailing Address - Fax:832-767-0888
Practice Address - Street 1:6829B NAVIGATION BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77011-1452
Practice Address - Country:US
Practice Address - Phone:832-649-2347
Practice Address - Fax:832-767-0888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG9562207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1264921Medicaid