Provider Demographics
NPI:1760952709
Name:MEMORIAL MEN'S HEALTH, LP
Entity Type:Organization
Organization Name:MEMORIAL MEN'S HEALTH, LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:JEANETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:VALDIVIESO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:713-376-9670
Mailing Address - Street 1:418 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77008-3912
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12505 MEMORIAL DR STE 300
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-6051
Practice Address - Country:US
Practice Address - Phone:713-376-9670
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-03
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty