Provider Demographics
NPI:1568727147
Name:MUNDO CHICO PEDIATRIC ASSOCIATES, LLC
Entity Type:Organization
Organization Name:MUNDO CHICO PEDIATRIC ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:JACQUELINE
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-590-9490
Mailing Address - Street 1:1617 BERGENLINE AVE.
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087-3208
Mailing Address - Country:US
Mailing Address - Phone:201-590-9490
Mailing Address - Fax:
Practice Address - Street 1:1617 BERGENLINE AVE.
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087-3208
Practice Address - Country:US
Practice Address - Phone:201-590-9490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08837600261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care