=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265109888
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MUNOZ PEDIATRIC AND ADOLESCENT CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2021
-----------------------------------------------------
Last Update Date | 06/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2406 EMMETT ST STE 100
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75211-5415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-776-8669
-----------------------------------------------------
Fax | 833-357-1698
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2406 EMMETT ST STE 100
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75211-5415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-776-8669
-----------------------------------------------------
Fax | 833-357-1698
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | EDNA MUNOZ
-----------------------------------------------------
Credential | CPNP
-----------------------------------------------------
Telephone | 469-776-8669
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------