Provider Demographics
NPI:1699572958
Name:MEN'S DIVISION PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:MEN'S DIVISION PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP-BC
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:PRESIDENT
Authorized Official - Phone:281-900-0597
Mailing Address - Street 1:1514 LYNNVIEW DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77055-3428
Mailing Address - Country:US
Mailing Address - Phone:281-900-0597
Mailing Address - Fax:346-299-7263
Practice Address - Street 1:11511 FM 1960 STE 102
Practice Address - Street 2:
Practice Address - City:HUFFMAN
Practice Address - State:TX
Practice Address - Zip Code:77336-2710
Practice Address - Country:US
Practice Address - Phone:832-832-8570
Practice Address - Fax:346-299-7263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-25
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care