Provider Demographics
NPI:1174750012
Name:SELECT SENIOR CLINIC AT AIRLINE LLC
Entity type:Organization
Organization Name:SELECT SENIOR CLINIC AT AIRLINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CLARETTA
Authorized Official - Middle Name:D
Authorized Official - Last Name:SAMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-234-7384
Mailing Address - Street 1:5815 AIRLINE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77076-4922
Mailing Address - Country:US
Mailing Address - Phone:713-691-4400
Mailing Address - Fax:713-691-4410
Practice Address - Street 1:5815 AIRLINE DR
Practice Address - Street 2:SUITE A
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77076-4922
Practice Address - Country:US
Practice Address - Phone:713-691-4400
Practice Address - Fax:713-691-4410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG4384207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty