Provider Demographics
NPI:1043472780
Name:EAGLE PASS PEDIATRIC HEALTH CLINIC
Entity Type:Organization
Organization Name:EAGLE PASS PEDIATRIC HEALTH CLINIC
Other - Org Name:
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:BBA
Authorized Official - Phone:830-773-1103
Mailing Address - Street 1:710 WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:EAGLE PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78852-5126
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
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:2008-06-25
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1790990802Medicaid
TX1104958081Medicaid
TX453819Medicare Oscar/Certification