Provider Demographics
NPI:1689888612
Name:SECOND MILE MISSION CENTER
Entity Type:Organization
Organization Name:SECOND MILE MISSION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CLIFF
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-261-9199
Mailing Address - Street 1:504 FM 1092
Mailing Address - Street 2:STE.I
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477
Mailing Address - Country:US
Mailing Address - Phone:281-261-9199
Mailing Address - Fax:281-403-1143
Practice Address - Street 1:504 MURPHY RD
Practice Address - Street 2:STE.I
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477-5419
Practice Address - Country:US
Practice Address - Phone:281-261-9199
Practice Address - Fax:281-403-1143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE38858Medicare UPIN
TXC21539Medicare UPIN