Basic Information
| Provider Information | |||||||||
| NPI: | 1508367616 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEALTHY PROMISE FAMILY PRACTICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 61160 | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784661160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3618842904 | ||||||||
| FaxNumber: | 3618841912 | ||||||||
| Practice Location | |||||||||
| Address1: | 5920 SARATOGA BLVD STE 470 | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784144108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3618842904 | ||||||||
| FaxNumber: | 3618841912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2018 | ||||||||
| LastUpdateDate: | 02/23/2018 | ||||||||
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| AuthorizedOfficialLastName: | HEUSNER-BANKS | ||||||||
| AuthorizedOfficialFirstName: | KYLA | ||||||||
| AuthorizedOfficialMiddleName: | FERMENA | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3618842904 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | R0869 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.