Provider Demographics
NPI:1699829184
Name:MARSHALL CENTER FOR PEDIATRICS
Entity Type:Organization
Organization Name:MARSHALL CENTER FOR PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:
Authorized Official - Last Name:VANCE
Authorized Official - Suffix:IV
Authorized Official - Credentials:
Authorized Official - Phone:530-626-2955
Mailing Address - Street 1:PO BOX 45680
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94145-0680
Mailing Address - Country:US
Mailing Address - Phone:530-626-1144
Mailing Address - Fax:
Practice Address - Street 1:4341 GOLDEN CENTER DR
Practice Address - Street 2:SUITE A
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-6816
Practice Address - Country:US
Practice Address - Phone:530-626-1144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2012-04-05
Deactivation Date:2011-12-28
Deactivation Code:
Reactivation Date:2012-04-05
Provider Licenses
StateLicense IDTaxonomies
CA208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty