Provider Demographics
NPI:1942441399
Name:BRAZOSPORT HEALTH ALLIANCE
Entity Type:Organization
Organization Name:BRAZOSPORT HEALTH ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:THEVENET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-299-1210
Mailing Address - Street 1:129 CIRCLE WAY ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-5249
Mailing Address - Country:US
Mailing Address - Phone:979-299-1210
Mailing Address - Fax:
Practice Address - Street 1:129 CIRCLE WAY ST
Practice Address - Street 2:SUITE A
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5249
Practice Address - Country:US
Practice Address - Phone:979-299-1210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRAZOSPORT REGIONAL HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-16
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization