Provider Demographics
NPI:1396018180
Name:HUTTO HEALTHY FUTURES PEDIATRIC CLINIC, LLC
Entity Type:Organization
Organization Name:HUTTO HEALTHY FUTURES PEDIATRIC CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-368-0200
Mailing Address - Street 1:210 HWY 79
Mailing Address - Street 2:STE. 104
Mailing Address - City:HUTTO
Mailing Address - State:TX
Mailing Address - Zip Code:78634-4533
Mailing Address - Country:US
Mailing Address - Phone:512-368-0200
Mailing Address - Fax:512-642-3805
Practice Address - Street 1:210 HWY 79
Practice Address - Street 2:STE. 104
Practice Address - City:HUTTO
Practice Address - State:TX
Practice Address - Zip Code:78634-4533
Practice Address - Country:US
Practice Address - Phone:512-368-0200
Practice Address - Fax:512-642-3805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04590363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty