Provider Demographics
NPI:1609348580
Name:PEDIATRIC KARE KLINIC PLLC
Entity Type:Organization
Organization Name:PEDIATRIC KARE KLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DELORIS
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:HARWELL
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, MSN, CPNP-PC
Authorized Official - Phone:469-602-5277
Mailing Address - Street 1:104 E US HIGHWAY 80 STE 190
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-8615
Mailing Address - Country:US
Mailing Address - Phone:469-602-5277
Mailing Address - Fax:469-995-7898
Practice Address - Street 1:104 E US HIGHWAY 80 STE 190
Practice Address - Street 2:
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126-8615
Practice Address - Country:US
Practice Address - Phone:469-602-5277
Practice Address - Fax:469-995-7898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-17
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX407416301Medicaid
TX407416302OtherTEXAS HEALTH STEPS