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General NPI Number Information
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NPI Number | 1356800791
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Entity Type | Organization
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Legal Business Name | GERONIMO VILLAGE PEDIATRICS, PLLC
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Dates
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Enumeration Date | 03/15/2019
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Last Update Date | 06/11/2019
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Provider Practice Location Address
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Address Line | 121 DENNIS DR
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City | SEGUIN
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State | TX
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Zip | 78155-0402
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Country | US
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Telephone | 830-372-8981
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Fax | 830-372-8984
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Provider Business Mailing Address
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Address Line | 121 DENNIS DR
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City | SEGUIN
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State | TX
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Zip | 78155-0402
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Country | US
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Telephone | 830-372-8981
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Fax | 830-372-8984
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Authorized Official
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Title or Position | OWNER
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Name | JODI GAYLE KOENIG
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Credential | CPNP-AC/PC
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Telephone | 830-372-8981
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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