Provider Demographics
NPI:1558489773
Name:1960 FAMILY PRACTICE, PA
Entity Type:Organization
Organization Name:1960 FAMILY PRACTICE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING DEPARTMENT
Authorized Official - Prefix:
Authorized Official - First Name:ANA
Authorized Official - Middle Name:
Authorized Official - Last Name:BORJA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-453-7224
Mailing Address - Street 1:PO BOX 4356
Mailing Address - Street 2:DEPARTMENT 667
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4356
Mailing Address - Country:US
Mailing Address - Phone:281-586-3888
Mailing Address - Fax:281-440-2020
Practice Address - Street 1:8850 SIX PINES DRIVE
Practice Address - Street 2:SUITE 190
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380
Practice Address - Country:US
Practice Address - Phone:281-586-3888
Practice Address - Fax:281-440-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX195426501Medicaid
TX195426501Medicaid