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General NPI Number Information
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NPI Number | 1326415779
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Entity Type | Organization
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Legal Business Name | PEDIAQ TEXAS LLC
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Dates
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Enumeration Date | 09/01/2015
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Last Update Date | 09/01/2015
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Provider Practice Location Address
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Address Line | 17101 PRESTON RD STE 115
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City | DALLAS
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State | TX
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Zip | 75248-1331
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Country | US
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Telephone | 214-984-3900
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Fax | 972-294-3343
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Provider Business Mailing Address
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Address Line | 17101 PRESTON RD STE 115
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City | DALLAS
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State | TX
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Zip | 75248-1331
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Country | US
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Telephone | 214-984-3900
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Fax | 972-294-3343
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Authorized Official
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Title or Position | OWNER
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Name | JON OSULLIVAN
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Credential |
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Telephone | 21498439000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0222X
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Taxonomy Name | Critical Care Pediatric Nurse Practitioner
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License Number | 226944
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 363LP0200X
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Taxonomy Name | Pediatric Nurse Practitioner
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License Number |
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License Number State |
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