Provider Demographics
NPI:1326415779
Name:PEDIAQ TEXAS LLC
Entity Type:Organization
Organization Name:PEDIAQ TEXAS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:OSULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:2149-843-9000
Mailing Address - Street 1:17101 PRESTON RD
Mailing Address - Street 2:STE 115
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-1331
Mailing Address - Country:US
Mailing Address - Phone:214-984-3900
Mailing Address - Fax:972-294-3343
Practice Address - Street 1:17101 PRESTON RD
Practice Address - Street 2:STE 115
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-1331
Practice Address - Country:US
Practice Address - Phone:214-984-3900
Practice Address - Fax:972-294-3343
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIAQ LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363LP0200X
TX226944363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
No363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical CareGroup - Single Specialty