Provider Demographics
NPI:1356656664
Name:PEDIATRIC PARTNERS MEDICAL PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:PEDIATRIC PARTNERS MEDICAL PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:FUCHIGAMI-BOST, RN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:951-252-8588
Mailing Address - Street 1:27699 JEFFERSON AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-2661
Mailing Address - Country:US
Mailing Address - Phone:951-252-8588
Mailing Address - Fax:951-252-8589
Practice Address - Street 1:1111 N CHINA LAKE BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-3131
Practice Address - Country:US
Practice Address - Phone:760-446-7337
Practice Address - Fax:760-446-7338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-11
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA09000099732080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty