Provider Demographics
NPI:1073870283
Name:SAN LUCAS PEDIATRIC, INC.
Entity Type:Organization
Organization Name:SAN LUCAS PEDIATRIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:AREVALO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-575-9090
Mailing Address - Street 1:4100 E COMMERCE WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-9501
Mailing Address - Country:US
Mailing Address - Phone:916-575-9090
Mailing Address - Fax:916-575-9099
Practice Address - Street 1:4100 E COMMERCE WAY STE 100
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95834-9501
Practice Address - Country:US
Practice Address - Phone:916-575-9090
Practice Address - Fax:916-575-9099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62749208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4346437Medicare PIN