Provider Demographics
NPI:1326131079
Name:VALLE VERDE PEDIATRICS MEDICAL GROUP
Entity Type:Organization
Organization Name:VALLE VERDE PEDIATRICS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RENDLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-487-8333
Mailing Address - Street 1:15525 POMERADO ROAD
Mailing Address - Street 2:#B1
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2465
Mailing Address - Country:US
Mailing Address - Phone:858-487-8333
Mailing Address - Fax:858-487-0856
Practice Address - Street 1:15525 POMERADO ROAD
Practice Address - Street 2:#B1
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2465
Practice Address - Country:US
Practice Address - Phone:858-487-8333
Practice Address - Fax:858-487-0856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00G642310174400000X
CAFNP18257208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1326131079Medicaid