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Forever Kids Pediatric Clinic

Organization Active NPI Clinic/Center · Canton, TX

NPI 1326435199 · NPPES record last updated Jan 26, 2023

Key facts

NPI
1326435199
Entity type
Organization (NPI type 2)
Primary specialty
Clinic/Center 261Q00000X
License
754047 (TX)
Legal business name
FOREVER KIDS PEDIATRIC CLINIC
Practice address
20783 Interstate 20 South Access Road
Canton, TX 75103
Phone
(214) 773-5669
Fax
(844) 678-6258
NPI assigned
Apr 20, 2015
Organization subpart
No

Authorized official

Name
Mrs. Lacy Dawn Burkes, RN , CPNP-PC
Title
Pediatric Nurse Practitioner
Phone
(214) 773-5669

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Laboratory certificates & supplier records

Name & address match These CMS records do not include an NPI. They are shown here because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
45D2111874Forever Kids Pediatric Clinic
20783 Interstate 20 S Access Rd, Canton, TX 75103		Certificate of waiverApr 17, 2028

National Provider Directory

Locations

205 W Tyler St
Canton, TX 75103
Phone (903) 567-5437

20783 Interstate 20 S Access Rd
Canton, TX 75103
Phone (214) 773-5669

20783 Interstate 20 S Access Rd
#R
Canton, TX 75103

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X 754047 TX Yes
Primary Care Clinic/Center 261QP2300X

Addresses

Primary practice location

20783 Interstate 20 South Access Road
Canton, TX 75103

Mailing address

20783 Interstate 20 South Access Road
Canton, TX 75103
Phone (903) 567-5437

Other identifiers

IdentifierTypeStateIssuer
1349815603MedicaidTX
1750646279OtherTXNPI

Other providers in Canton, TX

All providers in Canton, TX · Clinic/Center in Texas

Sources for this page

Verify at the official NPI Registry.