1770023624 NPI number — NEO2TEEN PEDIATRIC CLINIC, PA

Table of content: (NPI 1770023624)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770023624 NPI number — NEO2TEEN PEDIATRIC CLINIC, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEO2TEEN PEDIATRIC CLINIC, 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:
1770023624
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23723 SUNSET PEAK
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78258-7544
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-888-9960
Provider Business Mailing Address Fax Number:
210-888-9422

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6735 FM 78
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78244-1367
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-888-9960
Provider Business Practice Location Address Fax Number:
210-888-9422
Provider Enumeration Date:
02/26/2017

Additional Information

Authorized Official

Authorized Official Last Name:
ETOKHANA
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
210-888-9960

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  P2438 , 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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