Provider Demographics
NPI:1255567848
Name:DOMINION MEDICAL HEALTHCARE SERVICE
Entity type:Organization
Organization Name:DOMINION MEDICAL HEALTHCARE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:IRENONA
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-974-4400
Mailing Address - Street 1:8300 BISSONNET ST
Mailing Address - Street 2:SUITE 130
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77074-3900
Mailing Address - Country:US
Mailing Address - Phone:281-974-4400
Mailing Address - Fax:281-974-4386
Practice Address - Street 1:8300 BISSONNET ST
Practice Address - Street 2:SUITE 130
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-3900
Practice Address - Country:US
Practice Address - Phone:281-974-4400
Practice Address - Fax:281-974-4386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-09
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X, 225100000X, 225200000X, 247100000X, 208D00000X
TXPA 03172363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0A4561Medicare PIN