Provider Demographics
NPI:1730204264
Name:PEDIATRIC SPECIALTY RURAL HEALTH CLINIC
Entity type:Organization
Organization Name:PEDIATRIC SPECIALTY RURAL HEALTH CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:W
Authorized Official - Last Name:DE LOS SANTOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-773-1103
Mailing Address - Street 1:PO BOX 2368
Mailing Address - Street 2:
Mailing Address - City:EAGLE PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78853-2368
Mailing Address - Country:US
Mailing Address - Phone:830-773-1103
Mailing Address - Fax:830-757-8366
Practice Address - Street 1:710 WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:EAGLE PASS
Practice Address - State:TX
Practice Address - Zip Code:78852-5126
Practice Address - Country:US
Practice Address - Phone:830-773-1103
Practice Address - Fax:830-757-8366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3442174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX018235401Medicaid
TX1124150024OtherDEBORAH A. THOMSON PAC
TX1841347838OtherDR WENDY W. PITT
TX1851486500OtherDR RICARDO DE LOS SANTOS
TX018235401Medicaid