Healthcare Provider Details

I. General information

NPI: 1164876470
Provider Name (Legal Business Name): EL PASO KIDS KLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2016
Last Update Date: 04/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11351 JAMES WATT BUILDING F SUITE A
EL PASO TX
79936
US

IV. Provider business mailing address

11351 JAMES WATT BUILDING F SUITE A
EL PASO TX
79936
US

V. Phone/Fax

Practice location:
  • Phone: 915-225-3807
  • Fax: 915-225-3814
Mailing address:
  • Phone: 915-225-3807
  • Fax: 915-225-3814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP130736
License Number StateTX

VIII. Authorized Official

Name: HUMA Y LODHI
Title or Position: MD
Credential: MD
Phone: 915-225-3807