Provider Demographics
NPI:1619125770
Name:CLARK PEDIATRICS AND FAMILY MEDICINE INC
Entity Type:Organization
Organization Name:CLARK PEDIATRICS AND FAMILY MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:MAILE
Authorized Official - Last Name:TOMLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-458-7736
Mailing Address - Street 1:15 MAREBLU
Mailing Address - Street 2:SUITE 340
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-3015
Mailing Address - Country:US
Mailing Address - Phone:949-831-1466
Mailing Address - Fax:949-831-1462
Practice Address - Street 1:15 MAREBLU
Practice Address - Street 2:SUITE 340
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-3015
Practice Address - Country:US
Practice Address - Phone:949-831-1466
Practice Address - Fax:949-831-1462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA18257174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty