Provider Demographics
NPI:1669834842
Name:EMPRISE NETWORK LLC
Entity Type:Organization
Organization Name:EMPRISE NETWORK LLC
Other - Org Name:MONT BELVIEU FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROSANNA
Authorized Official - Middle Name:H
Authorized Official - Last Name:KALLAY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD(C)
Authorized Official - Phone:281-705-5882
Mailing Address - Street 1:9235 N HIGHWAY 146
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MONT BELVIEU
Mailing Address - State:TX
Mailing Address - Zip Code:77523-7876
Mailing Address - Country:US
Mailing Address - Phone:281-385-8111
Mailing Address - Fax:832-307-7102
Practice Address - Street 1:9235 N HIGHWAY 146
Practice Address - Street 2:SUITE 3
Practice Address - City:MONT BELVIEU
Practice Address - State:TX
Practice Address - Zip Code:77523-7876
Practice Address - Country:US
Practice Address - Phone:281-385-8111
Practice Address - Fax:832-307-7102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-25
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9314207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX204225101Medicaid
TX204225101Medicaid