Provider Demographics
NPI:1356303168
Name:TLC PEDIATRICS MEDICAL GROUP
Entity Type:Organization
Organization Name:TLC PEDIATRICS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOSIANE
Authorized Official - Middle Name:SUZANNE
Authorized Official - Last Name:DAGOSTINO
Authorized Official - Suffix:
Authorized Official - Credentials:CMM
Authorized Official - Phone:949-493-1383
Mailing Address - Street 1:30210 RANCHO VIEJO RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-1574
Mailing Address - Country:US
Mailing Address - Phone:949-493-7337
Mailing Address - Fax:949-493-1418
Practice Address - Street 1:30210 RANCHO VIEJO RD
Practice Address - Street 2:SUITE A
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-1574
Practice Address - Country:US
Practice Address - Phone:949-493-7337
Practice Address - Fax:949-493-1418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0081160Medicaid