Provider Demographics
NPI:1851486500
Name:PEDIATRIC SPECIALTY RURAL HEALTH CLINIC,LTD
Entity Type:Organization
Organization Name:PEDIATRIC SPECIALTY RURAL HEALTH CLINIC,LTD
Other - Org Name:D/B/A EAGLE PASS PEDIATRIC HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:W
Authorized Official - Last Name:DE LOS SANTOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-773-1103
Mailing Address - Street 1:PO BOX 2368
Mailing Address - Street 2:
Mailing Address - City:EAGLE PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78853-2368
Mailing Address - Country:US
Mailing Address - Phone:830-773-1103
Mailing Address - Fax:830-757-8366
Practice Address - Street 1:710 WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:EAGLE PASS
Practice Address - State:TX
Practice Address - Zip Code:78852-5126
Practice Address - Country:US
Practice Address - Phone:830-773-1103
Practice Address - Fax:830-757-8366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3442261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130941102OtherDR.RICARDO DE LOS SANTOS
TX742708192OtherTAX ID
TX8127J1OtherBLUECROSSBLUESHIELD
TX8127J1OtherBLUECROSSBLUESHIELD
TX742708192OtherTAX ID
TX130941102OtherDR.RICARDO DE LOS SANTOS
TXC15128Medicare UPIN
TX453935Medicare ID - Type UnspecifiedPEDIATRICSPECIALTYRURALHE