Provider Demographics
NPI:1740570092
Name:PRI-MED FAMILY CLINIC & WELLNESS CENTER
Entity Type:Organization
Organization Name:PRI-MED FAMILY CLINIC & WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:O
Authorized Official - Last Name:KANU
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, APN, FNP-C
Authorized Official - Phone:713-303-9064
Mailing Address - Street 1:12221 S KIRKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477-3044
Mailing Address - Country:US
Mailing Address - Phone:713-303-9064
Mailing Address - Fax:
Practice Address - Street 1:12221 S KIRKWOOD RD
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477-3044
Practice Address - Country:US
Practice Address - Phone:713-303-9064
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX595403207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty