Provider Demographics
NPI:1821158114
Name:CHILDREN'S MEDICAL CLINIC
Entity Type:Organization
Organization Name:CHILDREN'S MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:BANNISTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-786-5800
Mailing Address - Street 1:729 SUNRISE AVE
Mailing Address - Street 2:SUITE 501
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4565
Mailing Address - Country:US
Mailing Address - Phone:916-786-5800
Mailing Address - Fax:916-773-3001
Practice Address - Street 1:729 SUNRISE AVE
Practice Address - Street 2:SUITE 501
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4565
Practice Address - Country:US
Practice Address - Phone:916-786-5800
Practice Address - Fax:916-773-3001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG031541174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA44802Medicaid