Healthcare Provider Details

I. General information

NPI: 1336266642
Provider Name (Legal Business Name): PETERSBURG ISD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 WEST 4TH STREET
PETERSBURG TX
79250
US

IV. Provider business mailing address

1411 W 4TH ST P O BOX 160
PETERSBURG TX
79250
US

V. Phone/Fax

Practice location:
  • Phone: 806-667-3585
  • Fax: 806-667-3463
Mailing address:
  • Phone: 806-667-3585
  • Fax: 806-667-3463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State

VIII. Authorized Official

Name: DARLENEA M ROBERTSON
Title or Position: BUSINESS MANAGER
Credential:
Phone: 806-667-3585