Provider Demographics
NPI:1033614334
Name:PEDIATRIC ASSOCIATES PROF LLC
Entity Type:Organization
Organization Name:PEDIATRIC ASSOCIATES PROF LLC
Other - Org Name:TEEN CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-249-2421
Mailing Address - Street 1:947 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-5716
Mailing Address - Country:US
Mailing Address - Phone:970-249-2421
Mailing Address - Fax:970-249-1203
Practice Address - Street 1:910 S 4TH ST
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-4226
Practice Address - Country:US
Practice Address - Phone:970-249-2421
Practice Address - Fax:970-249-1203
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC ASSOCIATES PROF LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty