MEDICARE: PEDIATRIC KIDS LAND CLINIC P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

General Provider Information

NPI Number	:	1871773010
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC KIDS LAND CLINIC P.A.

Provider Business Mailing Address
First Line	:	4109 N CONWAY AVE
Second Line	:
City	:	PALMHURST
State	:	TX
Zip	:	78573-1309
Country	:	US
Telephone Number	:	956-451-4221
Fax Number	:	956-994-1696

Provider Business Practice Location Address
First Line	:	4109 N CONWAY AVE
Second Line	:
City	:	PALMHURST
State	:	TX
Zip	:	78573-1309
Country	:	US
Telephone Number	:	956-451-4221
Fax Number	:	956-994-1696

Authorized Official
Title or Position	:	OWNER
Name	:	DR. FADI M TORRES
Credential	:	M.D.
Telephone Number	:	956-451-4221

Provider Enumeration Date	:	11/05/2007
Last Update Date	:	11/06/2007

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