Provider Demographics
NPI:1063557064
Name:STAFFORD COMMUNITY CLINIC, LLC
Entity type:Organization
Organization Name:STAFFORD COMMUNITY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:AGUEDA
Authorized Official - Middle Name:
Authorized Official - Last Name:LARA-SMALLING
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:281-777-0599
Mailing Address - Street 1:13004 MURPHY RD
Mailing Address - Street 2:SUITE 224
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477-3971
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13004 MURPHY RD
Practice Address - Street 2:SUITE 224
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477-3971
Practice Address - Country:US
Practice Address - Phone:281-777-0599
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Not Answered261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain