Provider Demographics
NPI:1790755064
Name:SKY PEDIATRIC, INC.
Entity Type:Organization
Organization Name:SKY PEDIATRIC, INC.
Other - Org Name:SKY PEDIATRIC THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNDBLADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-797-9007
Mailing Address - Street 1:1929 MAIN ST
Mailing Address - Street 2:#103
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-0509
Mailing Address - Country:US
Mailing Address - Phone:949-797-9007
Mailing Address - Fax:949-797-9234
Practice Address - Street 1:1929 MAIN ST
Practice Address - Street 2:#103
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-0509
Practice Address - Country:US
Practice Address - Phone:949-797-9007
Practice Address - Fax:949-797-9234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2251P0200X, 225XP0200X
CA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
Not Answered225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
Not Answered235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ36141ZOtherBLUE SHIELD
CAZZZ65557ZOtherBLUE SHIELD