Provider Demographics
NPI:1851457303
Name:WT. MT. HOUSTON DIALYSIS CENTER
Entity Type:Organization
Organization Name:WT. MT. HOUSTON DIALYSIS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LEA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGALINO
Authorized Official - Suffix:
Authorized Official - Credentials:BSN, RN CCRN
Authorized Official - Phone:281-820-4880
Mailing Address - Street 1:2506 WT. MT. HOUSTON RD.
Mailing Address - Street 2:STE. A
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77018
Mailing Address - Country:US
Mailing Address - Phone:281-820-4880
Mailing Address - Fax:281-820-7062
Practice Address - Street 1:2506 WT. MT. HOUSTON RD.
Practice Address - Street 2:STE. A
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77018
Practice Address - Country:US
Practice Address - Phone:281-820-4880
Practice Address - Fax:281-820-7062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008242261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX672529Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER