Provider Demographics
NPI:1689014334
Name:LITTLE PLUM BLOSSOM PEDIATRICS, PLLC
Entity Type:Organization
Organization Name:LITTLE PLUM BLOSSOM PEDIATRICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-441-2266
Mailing Address - Street 1:311 S FM 1187
Mailing Address - Street 2:300
Mailing Address - City:ALEDO
Mailing Address - State:TX
Mailing Address - Zip Code:76008-6449
Mailing Address - Country:US
Mailing Address - Phone:817-441-2266
Mailing Address - Fax:877-293-3512
Practice Address - Street 1:311 S FM 1187
Practice Address - Street 2:300
Practice Address - City:ALEDO
Practice Address - State:TX
Practice Address - Zip Code:76008-6449
Practice Address - Country:US
Practice Address - Phone:817-441-2266
Practice Address - Fax:877-293-3512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM9285261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care