Provider Demographics
NPI:1912385881
Name:KIDS CLINIC AT CY-FAIR PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:KIDS CLINIC AT CY-FAIR PROFESSIONAL CORPORATION
Other - Org Name:PEGGY WONGSA MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SERENE
Authorized Official - Middle Name:
Authorized Official - Last Name:WONGSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-897-1122
Mailing Address - Street 1:11302 FALLBROOK DR STE 305
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77065-4265
Mailing Address - Country:US
Mailing Address - Phone:281-897-1122
Mailing Address - Fax:281-897-0777
Practice Address - Street 1:11302 FALLBROOK DR STE 305
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77065-4265
Practice Address - Country:US
Practice Address - Phone:281-897-1122
Practice Address - Fax:281-897-0777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-12
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0204208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty