Provider Demographics
NPI:1679767248
Name:BRAZOS TECH MANAGEMENT
Entity type:Organization
Organization Name:BRAZOS TECH MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:HUISMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-798-9103
Mailing Address - Street 1:PO BOX 1235
Mailing Address - Street 2:
Mailing Address - City:BRAZORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77422-1235
Mailing Address - Country:US
Mailing Address - Phone:979-798-9103
Mailing Address - Fax:979-798-9109
Practice Address - Street 1:324 NORTH BROOKS
Practice Address - Street 2:
Practice Address - City:BRAZORIA
Practice Address - State:TX
Practice Address - Zip Code:77422
Practice Address - Country:US
Practice Address - Phone:979-798-9103
Practice Address - Fax:979-798-9109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107231223G0001X
133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty