Healthcare Provider Details

I. General information

NPI: 1902094105
Provider Name (Legal Business Name): EL PICC STAT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2007
Last Update Date: 10/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 W JEFFERSON ST
BROWNSVILLE TX
78520-6338
US

IV. Provider business mailing address

5308 PYRENEES DR
WICHITA FALLS TX
76310-3949
US

V. Phone/Fax

Practice location:
  • Phone: 940-781-8837
  • Fax: 940-692-4136
Mailing address:
  • Phone: 940-781-8837
  • Fax: 940-692-4136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberF6922
License Number StateTX

VIII. Authorized Official

Name: MRS. MARY M BROOKING
Title or Position: ADMINISTRATOR
Credential: CMOM,CMIS
Phone: 940-781-8837