Provider Demographics
NPI:1144424466
Name:SEQUOIA PEDIATRIC GROUP, INC.
Entity Type:Organization
Organization Name:SEQUOIA PEDIATRIC GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:A
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-717-5670
Mailing Address - Street 1:P.O. BOX 7346
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93290-7346
Mailing Address - Country:US
Mailing Address - Phone:800-717-5670
Mailing Address - Fax:866-757-9283
Practice Address - Street 1:400 W MINERAL KING AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-6237
Practice Address - Country:US
Practice Address - Phone:800-717-5670
Practice Address - Fax:866-757-9283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0102040Medicaid