Provider Demographics
NPI:1508832288
Name:WATERSHED AT CLEAR LAKE
Entity Type:Organization
Organization Name:WATERSHED AT CLEAR LAKE
Other - Org Name:WATERSHED AT CLEAR LAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:S
Authorized Official - Last Name:KIRSE
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:561-361-6608
Mailing Address - Street 1:20 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-4127
Mailing Address - Country:US
Mailing Address - Phone:561-361-6608
Mailing Address - Fax:561-361-9857
Practice Address - Street 1:200 CONGRESS PARK DR
Practice Address - Street 2:SUITE 100
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33445-4609
Practice Address - Country:US
Practice Address - Phone:561-361-6608
Practice Address - Fax:561-361-9857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2210-A283X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherTAX ID NUMBER