Provider Demographics
NPI:1174799100
Name:MARIDIAN CLINICAL CARE
Entity type:Organization
Organization Name:MARIDIAN CLINICAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-970-6089
Mailing Address - Street 1:PO BOX 90639
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77290-0639
Mailing Address - Country:US
Mailing Address - Phone:281-970-6089
Mailing Address - Fax:281-970-6105
Practice Address - Street 1:13323 DOTSON RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-4303
Practice Address - Country:US
Practice Address - Phone:281-970-6089
Practice Address - Fax:281-970-6105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00410VMedicare PIN