Basic Information
| Provider Information | |||||||||
| NPI: | 1346514619 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRISTINE OB-GYN CARE PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13523 HARGRAVE RD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770703829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2812064496 | ||||||||
| FaxNumber: | 2812064487 | ||||||||
| Practice Location | |||||||||
| Address1: | 13523 HARGRAVE RD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770703829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2812064496 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2012 | ||||||||
| LastUpdateDate: | 11/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | OGUNLADE | ||||||||
| AuthorizedOfficialFirstName: | IYABODE | ||||||||
| AuthorizedOfficialMiddleName: | MUNIRAT | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2812064496 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 11/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | M8471 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
| ID | Type | State | Issuer | Description | 411162701 | 05 | TX | MEDICAID | 297102001 | 05 | TX | MEDICAID |