Provider Demographics
NPI:1467573311
Name:PEDIPLACE
Entity Type:Organization
Organization Name:PEDIPLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-436-7962
Mailing Address - Street 1:502 S OLD ORCHARD LN STE 126
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-4374
Mailing Address - Country:US
Mailing Address - Phone:972-436-7962
Mailing Address - Fax:972-353-5780
Practice Address - Street 1:502 S OLD ORCHARD LN STE 126
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-4374
Practice Address - Country:US
Practice Address - Phone:972-436-7962
Practice Address - Fax:972-353-5780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX091930002Medicaid
TX091930001Medicaid