Provider Demographics
NPI:1710492400
Name:SPACE CITY NP SERVICES
Entity Type:Organization
Organization Name:SPACE CITY NP SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP
Authorized Official - Prefix:
Authorized Official - First Name:DANESE
Authorized Official - Middle Name:
Authorized Official - Last Name:REXROAD
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:832-692-4416
Mailing Address - Street 1:301 FALCON LAKE DR
Mailing Address - Street 2:
Mailing Address - City:FRIENDSWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77546-5465
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 FALCON LAKE DR
Practice Address - Street 2:
Practice Address - City:FRIENDSWOOD
Practice Address - State:TX
Practice Address - Zip Code:77546-5465
Practice Address - Country:US
Practice Address - Phone:832-692-4416
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty