Provider Demographics
NPI:1932328986
Name:ISLAND HEALTH CENTER, P.A.
Entity Type:Organization
Organization Name:ISLAND HEALTH CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LORI
Authorized Official - Middle Name:L
Authorized Official - Last Name:ANTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:409-762-7646
Mailing Address - Street 1:4623 FORT CROCKETT BLVD
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77551-5962
Mailing Address - Country:US
Mailing Address - Phone:409-762-7646
Mailing Address - Fax:
Practice Address - Street 1:4623 FORT CROCKETT BLVD
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77551-5962
Practice Address - Country:US
Practice Address - Phone:409-762-7646
Practice Address - Fax:409-762-9223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC4392111NR0400X
TXK6521261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
Not Answered261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDC4392OtherLICENSE
TX8H8092OtherBLUE CROSS BLUESHIELD
TX1629102231OtherNPI 1
TX8H8091OtherBLUE CROSS BLUE SHIELD
TXK6521OtherLICENSE
TXK6521OtherLICENSE
TXDC4392OtherLICENSE
TXG50031Medicare UPIN