Healthcare Provider Details

I. General information

NPI: 1730204264
Provider Name (Legal Business Name): PEDIATRIC SPECIALTY RURAL HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 11/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 WILLIAMS ST
EAGLE PASS TX
78852-5126
US

IV. Provider business mailing address

PO BOX 2368
EAGLE PASS TX
78853-2368
US

V. Phone/Fax

Practice location:
  • Phone: 830-773-1103
  • Fax: 830-757-8366
Mailing address:
  • Phone: 830-773-1103
  • Fax: 830-757-8366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberF3442
License Number StateTX

VIII. Authorized Official

Name: MRS. DEBRA W DE LOS SANTOS
Title or Position: CEO
Credential:
Phone: 830-773-1103