Provider Demographics
NPI:1467502971
Name:SEQUOIA PEDIATRIC ORTHOPAEDICS MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SEQUOIA PEDIATRIC ORTHOPAEDICS MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:HENNRIKUS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:559-324-7300
Mailing Address - Street 1:1187 N WILLOW AVE STE 103
Mailing Address - Street 2:PMB#17
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-4411
Mailing Address - Country:US
Mailing Address - Phone:559-324-7300
Mailing Address - Fax:559-324-7350
Practice Address - Street 1:9300 VALLEY CHILDRENS PL
Practice Address - Street 2:#FE10
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93638-8761
Practice Address - Country:US
Practice Address - Phone:559-353-5944
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41574207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0085690Medicaid
CAZZZ60690ZOtherBLUE CROSS & BLUE SHIELD