Provider Demographics
NPI:1609221753
Name:TRI-COASTAL ANCILLARIES LLC
Entity Type:Organization
Organization Name:TRI-COASTAL ANCILLARIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:W
Authorized Official - Last Name:SPANGLER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:832-919-8221
Mailing Address - Street 1:PO BOX 4481
Mailing Address - Street 2:MSC# 400
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4481
Mailing Address - Country:US
Mailing Address - Phone:832-919-8221
Mailing Address - Fax:281-605-6705
Practice Address - Street 1:646 FM 517 RD W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:TX
Practice Address - Zip Code:77539-3904
Practice Address - Country:US
Practice Address - Phone:832-919-8221
Practice Address - Fax:281-605-6705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-26
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4728207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty