1760735922 NPI number — PEDIATRIC CLINIC OF ROCKWALL, PA

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 1760735922 NPI number — PEDIATRIC CLINIC OF ROCKWALL, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC CLINIC OF ROCKWALL, PA
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:
1760735922
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6800 HERITAGE PKWY
Provider Second Line Business Mailing Address:
201
Provider Business Mailing Address City Name:
ROCKWALL
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75087-8746
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-463-7337
Provider Business Mailing Address Fax Number:
972-463-7004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6800 HERITAGE PKWY
Provider Second Line Business Practice Location Address:
201
Provider Business Practice Location Address City Name:
ROCKWALL
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75087-8746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-463-7337
Provider Business Practice Location Address Fax Number:
972-463-7004
Provider Enumeration Date:
10/24/2012

Additional Information

Authorized Official

Authorized Official Last Name:
STILES
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
214-454-9452

Provider Taxonomy Codes

  • Taxonomy code: 2080A0000X , with the licence number:  H8853 , 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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