Provider Demographics
NPI:1497759211
Name:THE WOODLANDS SPORTS MEDICINE CENTRE, PA
Entity Type:Organization
Organization Name:THE WOODLANDS SPORTS MEDICINE CENTRE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:R
Authorized Official - Last Name:GLADDEN
Authorized Official - Suffix:IV
Authorized Official - Credentials:LVN
Authorized Official - Phone:281-367-0400
Mailing Address - Street 1:1441 WOODSTEAD CT
Mailing Address - Street 2:STE 300
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77380-1449
Mailing Address - Country:US
Mailing Address - Phone:281-367-0400
Mailing Address - Fax:281-367-1201
Practice Address - Street 1:1441 WOODSTEAD CT
Practice Address - Street 2:STE 300
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-1449
Practice Address - Country:US
Practice Address - Phone:281-367-0400
Practice Address - Fax:281-367-1201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherTAX ID
TX00U76QMedicare ID - Type Unspecified
TX=========OtherTAX ID