Healthcare Provider Details

I. General information

NPI: 1134250970
Provider Name (Legal Business Name): CORPUS CHRISTI TOTS & TEENS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 09/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6434 SARATOGA BLVD
CORPUS CHRISTI TX
78414-3425
US

IV. Provider business mailing address

6434 SARATOGA BLVD
CORPUS CHRISTI TX
78414-3425
US

V. Phone/Fax

Practice location:
  • Phone: 361-991-1885
  • Fax: 361-991-1839
Mailing address:
  • Phone: 361-991-1885
  • Fax: 361-991-1839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberK5826
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number605088
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number533345
License Number StateTX

VIII. Authorized Official

Name: EDWARD LEE BORCHARD
Title or Position: PRESIDENT
Credential: M.D.
Phone: 361-991-1885