Provider Demographics
NPI:1245920396
Name:PEDS TOTS TO TEENS LLC
Entity type:Organization
Organization Name:PEDS TOTS TO TEENS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:USHA
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-259-3785
Mailing Address - Street 1:1180 MALL DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8101
Mailing Address - Country:US
Mailing Address - Phone:575-259-3785
Mailing Address - Fax:575-532-9221
Practice Address - Street 1:1180 MALL DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8101
Practice Address - Country:US
Practice Address - Phone:575-259-3785
Practice Address - Fax:575-532-9221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-11
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious DiseasesGroup - Multi-Specialty