Healthcare Provider Details

I. General information

NPI: 1871773010
Provider Name (Legal Business Name): PEDIATRIC KIDS LAND CLINIC P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2007
Last Update Date: 11/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4109 N CONWAY AVE
PALMHURST TX
78573-1309
US

IV. Provider business mailing address

4109 N CONWAY AVE
PALMHURST TX
78573-1309
US

V. Phone/Fax

Practice location:
  • Phone: 956-451-4221
  • Fax: 956-994-1696
Mailing address:
  • Phone: 956-451-4221
  • Fax: 956-994-1696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. FADI M TORRES
Title or Position: OWNER
Credential: M.D.
Phone: 956-451-4221