Provider Demographics
NPI:1104958081
Name:PEDIATRIC SPECIALTY RURAL HEALTH CLINIC, LTD.
Entity type:Organization
Organization Name:PEDIATRIC SPECIALTY RURAL HEALTH CLINIC, LTD.
Other - Org Name:
Other - Org Type:
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 1:710 WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:EAGLE PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78852-5126
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:2007-03-09
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208000000X, 261QR1300X
TXF3442261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121077504Medicaid
TX453819Medicare Oscar/Certification
TX1851486500OtherNPI - PSRHC, LTD
TX00251NMedicare ID - Type UnspecifiedDR. DE LOS SANTOS
TX121077505Medicaid
TX8127J1Medicare ID - Type UnspecifiedGROUP
TX111923201Medicaid