Provider Demographics
NPI:1528576378
Name:PRAETORIAN MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:PRAETORIAN MEDICAL GROUP LLC
Other - Org Name:PRAETORIAN MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:DEWAYNE
Authorized Official - Last Name:LANIER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:303-524-5972
Mailing Address - Street 1:1880 S DAIRY ASHFORD RD STE 106
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77077-4759
Mailing Address - Country:US
Mailing Address - Phone:813-279-2729
Mailing Address - Fax:
Practice Address - Street 1:2900 COMMERCIAL CENTER BLVD STE 102
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-6724
Practice Address - Country:US
Practice Address - Phone:813-279-2729
Practice Address - Fax:813-279-2729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-15
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care