=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164738142
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HIS HOLDINGS GROUP LLC, HIS KIDS AMBULATORY INFUSION CTR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2010
-----------------------------------------------------
Last Update Date | 08/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 812 S. HACKBERRY ST.
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-884-0972
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 423 TERRA COTTA
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78253-9218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-884-0972
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MS. KARIMA ONEKIE LEDBETTER
-----------------------------------------------------
Credential | R.N.
-----------------------------------------------------
Telephone | 210-884-0972
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QI0500X
-----------------------------------------------------
Taxonomy Name | Infusion Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251F00000X
-----------------------------------------------------
Taxonomy Name | Home Infusion Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------