Provider Demographics
NPI:1619421310
Name:HERITAGE FAMILY CLINIC
Entity Type:Organization
Organization Name:HERITAGE FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:AJOYAT
Authorized Official - Last Name:BAKAMA
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:832-515-9903
Mailing Address - Street 1:20923 KINGSLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450-5548
Mailing Address - Country:US
Mailing Address - Phone:832-515-9903
Mailing Address - Fax:
Practice Address - Street 1:11850 FM 1960 RD W
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77065-3840
Practice Address - Country:US
Practice Address - Phone:832-515-9903
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HERITAGE FAMILY CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP123192363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX502338Medicare PIN