Healthcare Provider Details

I. General information

NPI: 1104958081
Provider Name (Legal Business Name): PEDIATRIC SPECIALTY RURAL HEALTH CLINIC, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 WILLIAMS ST
EAGLE PASS TX
78852-5126
US

IV. Provider business mailing address

710 WILLIAMS ST
EAGLE PASS TX
78852-5126
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 TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License NumberF3442
License Number StateTX

VIII. Authorized Official

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