Provider Demographics
NPI:1538035035
Name:SOUTH PADRE ISLAND PEDIATRIC CLINIC PA
Entity type:Organization
Organization Name:SOUTH PADRE ISLAND PEDIATRIC CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-854-4626
Mailing Address - Street 1:3845 S PADRE ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78415-2919
Mailing Address - Country:US
Mailing Address - Phone:361-854-4626
Mailing Address - Fax:361-851-5193
Practice Address - Street 1:1210 GREGORY ST STE 2
Practice Address - Street 2:
Practice Address - City:TAFT
Practice Address - State:TX
Practice Address - Zip Code:78390-3045
Practice Address - Country:US
Practice Address - Phone:361-528-2595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-13
Last Update Date:2025-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health