Provider Demographics
NPI:1144462334
Name:BRAESWOOD VACCINE CLINIC,INC
Entity type:Organization
Organization Name:BRAESWOOD VACCINE CLINIC,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:HARMINDER
Authorized Official - Middle Name:S
Authorized Official - Last Name:CHANA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:832-251-0500
Mailing Address - Street 1:1940 FOUNTAIN VIEW DR
Mailing Address - Street 2:UNIT 204
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77057-3206
Mailing Address - Country:US
Mailing Address - Phone:832-251-0500
Mailing Address - Fax:832-251-0503
Practice Address - Street 1:8622 S BRAESWOOD BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77031-1301
Practice Address - Country:US
Practice Address - Phone:832-251-0500
Practice Address - Fax:832-251-0503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-02
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1258208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126374107Medicaid