Provider Demographics
NPI:1255573465
Name:PEDIATRIC AND ADOLESCENT CLINIC OF WEST TEXAS, P.A.
Entity type:Organization
Organization Name:PEDIATRIC AND ADOLESCENT CLINIC OF WEST TEXAS, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEOPOLDO
Authorized Official - Middle Name:A
Authorized Official - Last Name:CABRERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:806-722-4453
Mailing Address - Street 1:PO BOX 16367
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79490-6367
Mailing Address - Country:US
Mailing Address - Phone:806-722-4453
Mailing Address - Fax:806-722-4461
Practice Address - Street 1:542419TH ST
Practice Address - Street 2:STE 200
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79407-2106
Practice Address - Country:US
Practice Address - Phone:806-722-4453
Practice Address - Fax:806-722-4461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-02
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX122410706Medicaid