Provider Demographics
NPI:1023710332
Name:EAST TEXAS PREMIER PEDIATRICS PLLC
Entity type:Organization
Organization Name:EAST TEXAS PREMIER PEDIATRICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:CHARLIA
Authorized Official - Middle Name:DEVON
Authorized Official - Last Name:SWINK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-729-6038
Mailing Address - Street 1:210 AUTUMN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-7489
Mailing Address - Country:US
Mailing Address - Phone:214-729-6038
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER BLVD STE B
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3173
Practice Address - Country:US
Practice Address - Phone:936-671-3428
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty