Provider Demographics
NPI:1598232035
Name:PINE MEDICAL PLLC
Entity Type:Organization
Organization Name:PINE MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOROMOKE
Authorized Official - Middle Name:O
Authorized Official - Last Name:ODINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:832-844-0934
Mailing Address - Street 1:1412 S FRONT ST
Mailing Address - Street 2:
Mailing Address - City:BELLVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77418-3307
Mailing Address - Country:US
Mailing Address - Phone:832-844-0934
Mailing Address - Fax:
Practice Address - Street 1:1412 S FRONT ST
Practice Address - Street 2:
Practice Address - City:BELLVILLE
Practice Address - State:TX
Practice Address - Zip Code:77418-3307
Practice Address - Country:US
Practice Address - Phone:832-844-0934
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-01
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care