Provider Demographics
NPI:1215009212
Name:WEST SACRAMENTOPEDIATRIC MEDICAL GROUP,INC
Entity Type:Organization
Organization Name:WEST SACRAMENTOPEDIATRIC MEDICAL GROUP,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER, CO-OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:J
Authorized Official - Last Name:TARRANT
Authorized Official - Suffix:
Authorized Official - Credentials:RN,FNP
Authorized Official - Phone:916-371-3787
Mailing Address - Street 1:1050 JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95691-3304
Mailing Address - Country:US
Mailing Address - Phone:916-371-3787
Mailing Address - Fax:916-371-3790
Practice Address - Street 1:1050 JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95691-3304
Practice Address - Country:US
Practice Address - Phone:916-371-3787
Practice Address - Fax:916-371-3790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208000000X261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0101570OtherGROUP NUMBER FOR CHDP
CA1841836OtherPIN