Provider Demographics
NPI:1326117516
Name:PRIMARY PEDIATRIC AND ADOLESCENT CLINIC, INCORPORATED
Entity Type:Organization
Organization Name:PRIMARY PEDIATRIC AND ADOLESCENT CLINIC, INCORPORATED
Other - Org Name:HAVEN FAMILY MEDICAL CENTER, INCORPORATED
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:FALAHYAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MOKHTAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-466-8888
Mailing Address - Street 1:8599 HAVEN AVE
Mailing Address - Street 2:STE. 101
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-4849
Mailing Address - Country:US
Mailing Address - Phone:909-466-8888
Mailing Address - Fax:909-483-0164
Practice Address - Street 1:8599 HAVEN AVE
Practice Address - Street 2:STE. 101
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4849
Practice Address - Country:US
Practice Address - Phone:909-466-8888
Practice Address - Fax:909-483-0164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33327305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization