Basic Information
Provider Information | |||||||||
NPI: | 1215136130 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PEDI SPOT LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4965 PRESTON PARK BLVD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | PLANO | ||||||||
State: | TX | ||||||||
PostalCode: | 750935180 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 6601 MONTANA AVE | ||||||||
Address2: | SUITE G&H | ||||||||
City: | EL PASO | ||||||||
State: | TX | ||||||||
PostalCode: | 799252155 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9158387604 | ||||||||
FaxNumber: | 9157724633 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2007 | ||||||||
LastUpdateDate: | 03/03/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CASEY | ||||||||
AuthorizedOfficialFirstName: | NEIL | ||||||||
AuthorizedOfficialMiddleName: | E. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
AuthorizedOfficialTelephone: | 9725967700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
No ID Information.