Healthcare Provider Details

I. General information

NPI: 1033564232
Provider Name (Legal Business Name): CLINT PEDIATRIC NIGHT CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2016
Last Update Date: 04/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SAN ELIZARIO RD STE H
CLINT TX
79836-6739
US

IV. Provider business mailing address

100 SAN ELIZARIO RD STE H
CLINT TX
79836-6739
US

V. Phone/Fax

Practice location:
  • Phone: 915-209-3722
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberQ2172
License Number StateTX

VIII. Authorized Official

Name: CHUKWUJEKWU OKPALAJI
Title or Position: PRESIDENT
Credential:
Phone: 915-209-3722