Provider Demographics
NPI:1902094105
Name:EL PICC STAT
Entity Type:Organization
Organization Name:EL PICC STAT
Other - Org Name:ETTA CAVIN RN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BROOKING
Authorized Official - Suffix:
Authorized Official - Credentials:CMOM,CMIS
Authorized Official - Phone:940-781-8837
Mailing Address - Street 1:5308 PYRENEES DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76310-3949
Mailing Address - Country:US
Mailing Address - Phone:940-781-8837
Mailing Address - Fax:940-692-4136
Practice Address - Street 1:1040 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520-6338
Practice Address - Country:US
Practice Address - Phone:940-781-8837
Practice Address - Fax:940-692-4136
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROBERT L. MCBROOM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-12
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF6922173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC19018Medicare UPIN