Provider Demographics
NPI:1821532565
Name:EQUILIBRE CLINIC LLC
Entity Type:Organization
Organization Name:EQUILIBRE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:SIOBAIN
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, APRN, FNP-C
Authorized Official - Phone:713-588-9302
Mailing Address - Street 1:6025 METROPOLITAN DR STE 210
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-2409
Mailing Address - Country:US
Mailing Address - Phone:713-588-9302
Mailing Address - Fax:
Practice Address - Street 1:6025 METROPOLITAN DR STE 210
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-2409
Practice Address - Country:US
Practice Address - Phone:713-588-9302
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-15
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP130283364S00000X, 364S00000X, 364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGroup - Multi-Specialty
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult HealthGroup - Multi-Specialty