Provider Demographics
NPI:1326435199
Name:FOREVER KIDS PEDIATRIC CLINIC
Entity Type:Organization
Organization Name:FOREVER KIDS PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LACY
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:BURKES
Authorized Official - Suffix:
Authorized Official - Credentials:RN , CPNP-PC
Authorized Official - Phone:214-773-5669
Mailing Address - Street 1:20783 INTERSTATE 20 SOUTH ACCESS ROAD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:TX
Mailing Address - Zip Code:75103
Mailing Address - Country:US
Mailing Address - Phone:903-567-5437
Mailing Address - Fax:844-678-6258
Practice Address - Street 1:20783 INTERSTATE 20 SOUTH ACCESS ROAD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:TX
Practice Address - Zip Code:75103
Practice Address - Country:US
Practice Address - Phone:214-773-5669
Practice Address - Fax:844-678-6258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-20
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX754047261Q00000X
261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1349815603Medicaid
TX1750646279OtherNPI