=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053859637
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHERUB KIDZ PEDIATRICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2017
-----------------------------------------------------
Last Update Date | 02/03/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9318 LOUETTA RD SUITE 400
-----------------------------------------------------
City | SPRING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77379-6520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 346-808-5904
-----------------------------------------------------
Fax | 346-808-5913
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9318 LOUETTA RD SUITE 400
-----------------------------------------------------
City | SPRING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77379-6520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 346-808-5904
-----------------------------------------------------
Fax | 346-808-5913
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER/ OWNER
-----------------------------------------------------
Name | DEBORAH BORGMAN
-----------------------------------------------------
Credential | FNP
-----------------------------------------------------
Telephone | 346-808-5904
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | AP120780
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------