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General NPI Number Information
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NPI Number | 1023710332
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Entity Type | Organization
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Legal Business Name | EAST TEXAS PREMIER PEDIATRICS PLLC
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Dates
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Enumeration Date | 03/20/2023
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Last Update Date | 03/20/2023
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Provider Practice Location Address
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Address Line | 1 MEDICAL CENTER BLVD STE B
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City | LUFKIN
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State | TX
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Zip | 75904-3173
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Country | US
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Telephone | 936-671-3428
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Fax |
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Provider Business Mailing Address
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Address Line | 210 AUTUMN LAKE DR
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City | LUFKIN
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State | TX
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Zip | 75904-7489
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Country | US
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Telephone | 214-729-6038
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING
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Name | CHARLIA DEVON SWINK
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Credential |
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Telephone | 214-729-6038
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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