Provider Demographics
NPI:1154578292
Name:PROGRAM FOR SIDE EFFECTS MANAGEMENT
Entity type:Organization
Organization Name:PROGRAM FOR SIDE EFFECTS MANAGEMENT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:713-520-5288
Mailing Address - Street 1:3224 YOAKUM BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77006-3926
Mailing Address - Country:US
Mailing Address - Phone:713-520-5288
Mailing Address - Fax:713-521-7419
Practice Address - Street 1:3224 YOAKUM BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77006-3926
Practice Address - Country:US
Practice Address - Phone:713-520-5288
Practice Address - Fax:713-521-7419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-20
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty