Provider Demographics
NPI:1518440494
Name:NACOGDOCHES PEDIATRIC CARE
Entity Type:Organization
Organization Name:NACOGDOCHES PEDIATRIC CARE
Other - Org Name:NACOGDOCHES PEDIATRIC EXTENDED CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MISTI
Authorized Official - Middle Name:
Authorized Official - Last Name:HAJJ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-348-5945
Mailing Address - Street 1:2407 PINEHURST DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-2314
Mailing Address - Country:US
Mailing Address - Phone:318-348-5945
Mailing Address - Fax:
Practice Address - Street 1:124 CREEKBEND BLVD
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1780
Practice Address - Country:US
Practice Address - Phone:193-623-4085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-07
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM3000XAmbulatory Health Care FacilitiesClinic/CenterMedically Fragile Infants and Children Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4053464Medicaid