Provider Demographics
NPI:1073265104
Name:AB PEDIATRIC HEALTH CLINIC TOO PLLC
Entity Type:Organization
Organization Name:AB PEDIATRIC HEALTH CLINIC TOO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDRES
Authorized Official - Middle Name:D
Authorized Official - Last Name:BOADELLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:915-577-0455
Mailing Address - Street 1:1500 FINSTERWALD PL
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-6011
Mailing Address - Country:US
Mailing Address - Phone:817-209-4946
Mailing Address - Fax:
Practice Address - Street 1:12001 TIERRA ESTE RD
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79938-4573
Practice Address - Country:US
Practice Address - Phone:915-295-0455
Practice Address - Fax:915-706-4028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-20
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP5938OtherTEXAS LICENSE