Provider Demographics
NPI:1659768794
Name:CONSULTORIO MEDICO LATINO, LLC
Entity Type:Organization
Organization Name:CONSULTORIO MEDICO LATINO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLADYS
Authorized Official - Middle Name:V
Authorized Official - Last Name:SANTANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-485-6758
Mailing Address - Street 1:9501 LONG POINT RD
Mailing Address - Street 2:SUITE R
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77055-4253
Mailing Address - Country:US
Mailing Address - Phone:713-485-6758
Mailing Address - Fax:832-236-9682
Practice Address - Street 1:9501 LONG POINT RD
Practice Address - Street 2:SUITE R
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77055-4253
Practice Address - Country:US
Practice Address - Phone:713-485-6758
Practice Address - Fax:832-236-9682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-15
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty