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General NPI Number Information
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NPI Number | 1659184166
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Entity Type | Organization
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Legal Business Name | BIGFOOT PEDIATRICS LLC
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Dates
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Enumeration Date | 01/29/2025
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Last Update Date | 01/29/2025
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Provider Practice Location Address
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Address Line | 2515 CASTROVILLE RD STE 4
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City | SAN ANTONIO
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State | TX
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Zip | 78237-3361
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Country | US
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Telephone | 860-501-9739
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Fax |
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Provider Business Mailing Address
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Address Line | 101 FAZIO DR
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City | CIBOLO
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State | TX
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Zip | 78108-3292
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Country | US
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Telephone | 210-570-3323
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Fax | 857-219-4219
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Authorized Official
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Title or Position | OWNER
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Name | JUSTIN VINE
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Credential | PNP
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Telephone | 210-570-3323
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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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Taxonomy #2
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number |
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License Number State |
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