Provider Demographics
NPI:1861665572
Name:VA OUTPATIIENT CLINIC
Entity type:Organization
Organization Name:VA OUTPATIIENT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHCY MANG
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:KYLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-794-7223
Mailing Address - Street 1:PO BOX 300408
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77230-0408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3420 VETERANS CIR
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77707-2552
Practice Address - Country:US
Practice Address - Phone:409-981-8570
Practice Address - Fax:409-981-8569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-03
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332100000XSuppliersDepartment of Veterans Affairs (VA) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4547913OtherOTHER ID NUMBER