Healthcare Provider Details

I. General information

NPI: 1528316551
Provider Name (Legal Business Name): BUMPS N' BRUISES PEDIATRIC URGENT CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2012
Last Update Date: 08/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2251 MATLOCK RD
MANSFIELD TX
76063-3825
US

IV. Provider business mailing address

2251 MATLOCK RD
MANSFIELD TX
76063-3825
US

V. Phone/Fax

Practice location:
  • Phone: 330-495-6359
  • Fax:
Mailing address:
  • Phone: 330-495-6359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: EMMA HOLTON
Title or Position: PROVIDER ENROLLMENT COORDINATOR
Credential:
Phone: 804-643-2287