=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033494240
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PADRON WELLNESS CLINIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2011
-----------------------------------------------------
Last Update Date | 10/19/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 EMERALD ISLE DR STE 107
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75218-3949
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-321-4917
-----------------------------------------------------
Fax | 214-321-4914
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 381 CASA LINDA PLZ # 353
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75218-3471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-321-4917
-----------------------------------------------------
Fax | 214-321-4914
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DR. NICOLAS A PADRON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 214-321-4917
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number | H2662
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------