NPIMap

Organization Active NPI

William Nisimblat Mdpa

Doing business as Alice Pediatric Clinic

  • Pediatrics Physician
  • Alice, TX
National Provider Identifier
1477646271
Registry record updated Feb 9, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
Legal business name
WILLIAM NISIMBLAT MDPA
Doing business as
Alice Pediatric Clinic
Practice address
305 E Third St
Alice, TX 78332-4705
Phone
(361) 664-5291
Fax
(361) 668-1630
NPI assigned
Oct 2, 2006
Last updated
Feb 9, 2011By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 9, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
William Nisimblat, MDNPI 1700979739
Title
Owner
Phone
(361) 664-5291

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 208000000X Primary
Rural Health Clinic/Center 261QR1300X

Addresses

Primary practice location

305 E Third St
Alice, TX 78332-4705

Mailing address

PO Box 289
Alice, TX 78333-4705
Phone (361) 664-9353

Other names 1

  • Alice Pediatric Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100420001013 TX Part A Provider - Rural Health Clinic 3971630104 Practice locations: Alice, TX

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1477646271. Details of each certification follow.

Rural health clinic certification: CCN 453956

Legal name
WILLIAM NISIMBLAT MDPA
Doing business as
ALICE PEDIATRIC CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 14, 1994
Last certification
Jul 1, 2015
Ownership / control type
1A
Organization structure
OtherProprietary
Incorporated
Jul 12, 1989 in TX
Enrollment address
305 E 3Rd St
Alice, TX 78332-4705

Laboratory certificates & supplier records

Derived by NPIMap

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

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
45D0680723Alice Pediatric Clinic305 E 3Rd, Alice, TX 78332ComplianceOct 27, 2027

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 3

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Donna Lara Individual W-2 Managing EmployeeOffice Manager Jul 15, 2003
Carolina Nisimblat Individual Corporate DirectorSecretary Jul 18, 2018
Erik Nisimblat Individual 5% Or Greater Direct Ownership Interest Jul 18, 2018 100%
Corporate OfficerPresident & Medical Director Jul 18, 2018

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1159747200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1297209600000",
    "number": "1477646271",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 289",
            "city": "ALICE",
            "state": "TX",
            "postal_code": "783334705",
            "telephone_number": "361-664-9353"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "305 E THIRD ST",
            "city": "ALICE",
            "state": "TX",
            "postal_code": "783324705",
            "telephone_number": "361-664-5291",
            "fax_number": "361-668-1630"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WILLIAM NISIMBLAT MDPA",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-02",
        "last_updated": "2011-02-09",
        "status": "A",
        "authorized_official_last_name": "NISIMBLAT",
        "authorized_official_first_name": "WILLIAM",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "361-664-5291",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Alice Pediatric Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Alice, TX

Sources for this page

Verify at the official NPI Registry.