Provider Demographics
NPI:1871290825
Name:CLINICA FAMILIAR LA LUZ LLC
Entity type:Organization
Organization Name:CLINICA FAMILIAR LA LUZ LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NORBE
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:BASULTO BASULTO
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:713-660-1603
Mailing Address - Street 1:29310 PRAIRIE ROSE CT
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-7384
Mailing Address - Country:US
Mailing Address - Phone:832-937-5596
Mailing Address - Fax:832-937-5596
Practice Address - Street 1:29310 PRAIRIE ROSE CT
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-7384
Practice Address - Country:US
Practice Address - Phone:832-937-5596
Practice Address - Fax:832-937-5596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-09
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1861628505OtherBLUE CROSS AND BLUE SHIELD
TX1861628505OtherMOLINA
TX1861628505OtherOSCAR
TX1861628505OtherUNITED HEALTH CARE
TX1861628505Medicaid
TX1861628505OtherCOMMUNITY HEALTH CHOICE
TX1861628505OtherCIGNA
TX1861628505OtherAMBETTER
TX1861628505OtherAETNA