Healthcare Provider Details

I. General information

NPI: 1043472780
Provider Name (Legal Business Name): EAGLE PASS PEDIATRIC HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 04/06/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 WILLIAMS ST
EAGLE PASS TX
78852
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 TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

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