Provider Demographics
NPI:1790108454
Name:SHEPHERDS PEDIATRIC CARE
Entity Type:Organization
Organization Name:SHEPHERDS PEDIATRIC CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LONI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SHEPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:979-297-3949
Mailing Address - Street 1:106 CIRCLE WAY ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-5202
Mailing Address - Country:US
Mailing Address - Phone:979-297-3949
Mailing Address - Fax:979-297-3919
Practice Address - Street 1:106 CIRCLE WAY ST
Practice Address - Street 2:SUITE A
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5202
Practice Address - Country:US
Practice Address - Phone:979-297-3949
Practice Address - Fax:979-297-3919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-30
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN6017261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX214871001Medicaid