Provider Demographics
NPI:1033494240
Name:PADRON WELLNESS CLINIC PLLC
Entity Type:Organization
Organization Name:PADRON WELLNESS CLINIC PLLC
Other - Org Name:PADRON WELLNESS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:PADRON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-321-4917
Mailing Address - Street 1:381 CASA LINDA PLZ # 353
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75218-3471
Mailing Address - Country:US
Mailing Address - Phone:214-321-4917
Mailing Address - Fax:214-321-4914
Practice Address - Street 1:1000 EMERALD ISLE DR STE 107
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75218-3949
Practice Address - Country:US
Practice Address - Phone:214-321-4917
Practice Address - Fax:214-321-4914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2662305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service