Provider Demographics
NPI:1205101417
Name:THE CLINIC AT THE PORT
Entity type:Organization
Organization Name:THE CLINIC AT THE PORT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAHOMA
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:PEDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-551-6742
Mailing Address - Street 1:P.O. BOX 1822
Mailing Address - Street 2:
Mailing Address - City:LOS FRESNOS
Mailing Address - State:TX
Mailing Address - Zip Code:78566
Mailing Address - Country:US
Mailing Address - Phone:956-831-3400
Mailing Address - Fax:
Practice Address - Street 1:3150 N. INDIANA AVE
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78526
Practice Address - Country:US
Practice Address - Phone:956-831-3400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-21
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care