Healthcare Provider Details

I. General information

NPI: 1073265104
Provider Name (Legal Business Name): AB PEDIATRIC HEALTH CLINIC TOO PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2022
Last Update Date: 01/25/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12001 TIERRA ESTE RD
EL PASO TX
79938-4573
US

IV. Provider business mailing address

1500 FINSTERWALD PL
EL PASO TX
79936-6011
US

V. Phone/Fax

Practice location:
  • Phone: 915-295-0455
  • Fax: 915-706-4028
Mailing address:
  • Phone: 817-209-4946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ANDRES D BOADELLA
Title or Position: OWNER
Credential: MD
Phone: 915-577-0455