1184102147 NPI number — CIBOLO-SOUTH TEXAS CENTER FOR PEDIATRIC CARE

Table of content: (NPI 1184102147)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184102147 NPI number — CIBOLO-SOUTH TEXAS CENTER FOR PEDIATRIC CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CIBOLO-SOUTH TEXAS CENTER FOR PEDIATRIC CARE
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:
1184102147
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13750 SAN PEDRO AVE SUITE
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
BEXAR
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78232
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-561-3100
Provider Business Mailing Address Fax Number:
210-224-6367

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
580 CIBOLO VALLEY DRIVE
Provider Second Line Business Practice Location Address:
SUITE 221
Provider Business Practice Location Address City Name:
CIBOLO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-561-3100
Provider Business Practice Location Address Fax Number:
210-224-6367
Provider Enumeration Date:
08/01/2018

Additional Information

Authorized Official

Authorized Official Last Name:
BURNS
Authorized Official First Name:
DIANNA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
210-561-3100

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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