Provider Demographics
NPI:1386966505
Name:I-10 FAMILY CLINIC
Entity type:Organization
Organization Name:I-10 FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PRENTISS
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-637-8665
Mailing Address - Street 1:11929 EAST FWY
Mailing Address - Street 2:SUITE D
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77029-2025
Mailing Address - Country:US
Mailing Address - Phone:713-637-8665
Mailing Address - Fax:
Practice Address - Street 1:11929 EAST FWY
Practice Address - Street 2:SUITE D
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77029-2025
Practice Address - Country:US
Practice Address - Phone:713-637-8665
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-16
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM7120207Q00000X
TXPA00256363A00000X
TXPA00114363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty