Provider Demographics
NPI:1558910745
Name:UNIQUE PEDIATRIC MEDICAL CENTER INC.
Entity Type:Organization
Organization Name:UNIQUE PEDIATRIC MEDICAL CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ERNESTO
Authorized Official - Middle Name:REYES
Authorized Official - Last Name:MILLAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-776-5620
Mailing Address - Street 1:39000 BOB HOPE DR STE K211
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3215
Mailing Address - Country:US
Mailing Address - Phone:760-776-5620
Mailing Address - Fax:760-776-5626
Practice Address - Street 1:39000 BOB HOPE DR STE K211
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3215
Practice Address - Country:US
Practice Address - Phone:760-776-5620
Practice Address - Fax:760-776-5626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF91395Medicaid