Provider Demographics
NPI:1568169936
Name:HAVANA MEDICAL GROUP CORP
Entity Type:Organization
Organization Name:HAVANA MEDICAL GROUP CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DNP/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:YVDIT
Authorized Official - Middle Name:
Authorized Official - Last Name:CONCEPCION-PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP-C, APRN
Authorized Official - Phone:832-871-4777
Mailing Address - Street 1:715 TELEPHONE RD.
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77023-3117
Mailing Address - Country:US
Mailing Address - Phone:832-871-4777
Mailing Address - Fax:832-871-4776
Practice Address - Street 1:715 TELEPHONE RD.
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77023-3117
Practice Address - Country:US
Practice Address - Phone:832-871-4777
Practice Address - Fax:832-871-4776
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HAVANA MEDICAL GROUP.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty