Provider Demographics
NPI:1871875294
Name:MARYS CLINIC INC
Entity type:Organization
Organization Name:MARYS CLINIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ESTHER
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:979-540-2122
Mailing Address - Street 1:191 S MANSE AVE
Mailing Address - Street 2:
Mailing Address - City:GIDDINGS
Mailing Address - State:TX
Mailing Address - Zip Code:78942-3433
Mailing Address - Country:US
Mailing Address - Phone:979-540-2122
Mailing Address - Fax:979-540-2120
Practice Address - Street 1:191 S MANSE AVE
Practice Address - Street 2:
Practice Address - City:GIDDINGS
Practice Address - State:TX
Practice Address - Zip Code:78942-3433
Practice Address - Country:US
Practice Address - Phone:979-540-2122
Practice Address - Fax:979-540-2120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX257158364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily HealthGroup - Single Specialty