Basic Information
| Provider Information | |||||||||
| NPI: | 1215446497 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRISTINE BIRTH & WELLNESS CENTER LLC | ||||||||
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| OtherOrganizationName: | PRISTINE BIRTH AND WELLNESS - PROFESSIONAL GROUP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13523 HARGRAVE RD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770703829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2812064496 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6617 FM 2920 RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | SPRING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773792636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2812064496 | ||||||||
| FaxNumber: | 2812064487 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2017 | ||||||||
| LastUpdateDate: | 09/20/2017 | ||||||||
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| AuthorizedOfficialLastName: | OGUNLADE | ||||||||
| AuthorizedOfficialFirstName: | IYABODE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2812064496 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Midwife | 207V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.