Provider Demographics
NPI:1699147611
Name:SUN PRIMARY CARE CLINIC, PLLC
Entity type:Organization
Organization Name:SUN PRIMARY CARE CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:GHAZAVI
Authorized Official - Suffix:
Authorized Official - Credentials:ANP
Authorized Official - Phone:281-818-8448
Mailing Address - Street 1:10731 LONGMONT DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77042-2311
Mailing Address - Country:US
Mailing Address - Phone:713-242-1248
Mailing Address - Fax:206-666-4377
Practice Address - Street 1:4747 BELLAIRE BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:BELLAIRE
Practice Address - State:TX
Practice Address - Zip Code:77401-4527
Practice Address - Country:US
Practice Address - Phone:832-780-9598
Practice Address - Fax:206-666-4377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-29
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX773335261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care