Provider Demographics
NPI:1063803138
Name:HOUSTON LUNG CLINIC LLC
Entity type:Organization
Organization Name:HOUSTON LUNG CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RODRIGO
Authorized Official - Middle Name:E
Authorized Official - Last Name:MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-333-2522
Mailing Address - Street 1:92 TOMMY STALNAKER DR
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-9179
Mailing Address - Country:US
Mailing Address - Phone:478-333-2522
Mailing Address - Fax:478-333-3160
Practice Address - Street 1:92 TOMMY STALNAKER DR
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-9179
Practice Address - Country:US
Practice Address - Phone:478-333-2522
Practice Address - Fax:478-333-3160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-11
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052467207RP1001X, 207RS0012X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA915967282CMedicaid
GA511I290007Medicare PIN
GA915967282CMedicaid