1124078258 NPI number — TLC PEDIATRICS, P.A.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124078258 NPI number — TLC PEDIATRICS, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TLC PEDIATRICS, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124078258
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1105 CENTRAL EXPY N
Provider Second Line Business Mailing Address:
SUITE 320
Provider Business Mailing Address City Name:
ALLEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75013-6103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-747-5437
Provider Business Mailing Address Fax Number:
972-747-5497

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1105 CENTRAL EXPY N
Provider Second Line Business Practice Location Address:
SUITE 320
Provider Business Practice Location Address City Name:
ALLEN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75013-6103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-747-5437
Provider Business Practice Location Address Fax Number:
972-747-5497
Provider Enumeration Date:
05/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MOULTON
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
972-747-5437

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  L1138 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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