Healthcare Provider Details

I. General information

NPI: 1639197510
Provider Name (Legal Business Name): FLETCHER AND O'GRADY PEDIATRIC ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 04/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 CARE CIR
AMARILLO TX
79124-2105
US

IV. Provider business mailing address

17 CARE CIR
AMARILLO TX
79124-2105
US

V. Phone/Fax

Practice location:
  • Phone: 806-468-6280
  • Fax: 806-468-7174
Mailing address:
  • Phone: 806-468-6280
  • Fax: 806-468-7174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number675512
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. KELLY SUZANNE WHITE
Title or Position: OFFICE MANAGER
Credential:
Phone: 806-468-6280