1255573465 NPI number — PEDIATRIC AND ADOLESCENT CLINIC OF WEST TEXAS, P.A.

Table of content: (NPI 1255573465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255573465 NPI number — PEDIATRIC AND ADOLESCENT CLINIC OF WEST TEXAS, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC AND ADOLESCENT CLINIC OF WEST TEXAS, 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:
LEOPOLDO CABRERA
Provider Other Organization Name Type Code:
5
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:
1255573465
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 16367
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUBBOCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79490-6367
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-722-4453
Provider Business Mailing Address Fax Number:
806-722-4461

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
542419TH ST
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
LUBBOCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79407-2106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-722-4453
Provider Business Practice Location Address Fax Number:
806-722-4461
Provider Enumeration Date:
04/02/2009

Additional Information

Authorized Official

Authorized Official Last Name:
CABRERA
Authorized Official First Name:
LEOPOLDO
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
806-722-4453

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 122410706 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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