=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235784588
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHILDRENS CLINIC OF SOUTH TEXAS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2019
-----------------------------------------------------
Last Update Date | 08/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 612 W NOLANA AVE STE 330
-----------------------------------------------------
City | MCALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78504-3088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-630-2225
-----------------------------------------------------
Fax | 956-630-2275
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 612 W NOLANA AVE STE 330
-----------------------------------------------------
City | MCALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78504-3088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-630-2225
-----------------------------------------------------
Fax | 956-630-2275
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | STEPHANIE A DUBERT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 956-630-2225
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------