Healthcare Provider Details

I. General information

NPI: 1316502875
Provider Name (Legal Business Name): TCH PEDIATRIC ASSOCIATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2019
Last Update Date: 05/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 W 34TH ST STE 102
AUSTIN TX
78705-1916
US

IV. Provider business mailing address

PO BOX 847169
DALLAS TX
75284-7169
US

V. Phone/Fax

Practice location:
  • Phone: 512-467-1600
  • Fax: 512-302-0269
Mailing address:
  • Phone: 832-824-6631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: LAURA VILLAR
Title or Position: CBO - MANAGER
Credential:
Phone: 832-824-6631