Provider Demographics
NPI:1659306991
Name:INFANT JESUS CHILDRENS CLINIC PLC
Entity Type:Organization
Organization Name:INFANT JESUS CHILDRENS CLINIC PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-458-1430
Mailing Address - Street 1:210 TEMPLE AVE
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-2828
Mailing Address - Country:US
Mailing Address - Phone:804-520-6137
Mailing Address - Fax:804-520-7394
Practice Address - Street 1:210 TEMPLE AVE
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2828
Practice Address - Country:US
Practice Address - Phone:804-520-6137
Practice Address - Fax:804-520-7394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
17660OtherCARENET
214596OtherANTHEM
23468OtherSENTARA
120154OtherUNITED HEALTH CARE
214598OtherANTHEM
=========OtherSOUTHERN HEALTH
=========OtherCIGNA
17660OtherCARENET
23468OtherSENTARA