Basic Information
| Provider Information | |||||||||
| NPI: | 1225252737 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOUNDATION ANCILLARY SERVICES AFFILIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3108 | ||||||||
| Address2: | DEPT 902 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772533108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135816950 | ||||||||
| FaxNumber: | 7135816951 | ||||||||
| Practice Location | |||||||||
| Address1: | 5420 WEST LOOP S | ||||||||
| Address2: | SUITE 3100 | ||||||||
| City: | BELLAIRE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774012107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135816950 | ||||||||
| FaxNumber: | 7135816951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2007 | ||||||||
| LastUpdateDate: | 08/05/2011 | ||||||||
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| AuthorizedOfficialLastName: | VICTORIAN | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
| AuthorizedOfficialMiddleName: | DENISE | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7135816950 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | R.N. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZS0410X | Y | 193400000X SINGLE SPECIALTY GROUP |
No ID Information.