Provider Demographics
NPI:1568944346
Name:PROYOUTH PEDIATRIC HEALTH & WELLNESS PC
Entity Type:Organization
Organization Name:PROYOUTH PEDIATRIC HEALTH & WELLNESS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:SUNNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SKILES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-626-3060
Mailing Address - Street 1:6815 FIVE STAR BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-2691
Mailing Address - Country:US
Mailing Address - Phone:916-626-3060
Mailing Address - Fax:916-626-3063
Practice Address - Street 1:6815 FIVE STAR BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-2691
Practice Address - Country:US
Practice Address - Phone:916-626-3060
Practice Address - Fax:916-626-3063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66133261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA44802Medicaid