1609348580 NPI number — PEDIATRIC KARE KLINIC PLLC

Table of content: (NPI 1609348580)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609348580 NPI number — PEDIATRIC KARE KLINIC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC KARE KLINIC PLLC
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:
1609348580
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 E US HIGHWAY 80 STE 190
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORNEY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75126-8615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-602-5277
Provider Business Mailing Address Fax Number:
469-995-7898

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 E US HIGHWAY 80 STE 190
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORNEY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75126-8615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-602-5277
Provider Business Practice Location Address Fax Number:
469-995-7898
Provider Enumeration Date:
12/17/2018

Additional Information

Authorized Official

Authorized Official Last Name:
HARWELL
Authorized Official First Name:
DELORIS
Authorized Official Middle Name:
RENEE
Authorized Official Title or Position:
PEDIATRIC NURSE PRACTITIONER
Authorized Official Telephone Number:
469-602-5277

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: 407416301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 407416302 . This is a "TEXAS HEALTH STEPS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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