Provider Demographics
NPI:1881643021
Name:SOUTHERN ORANGE COUNTY PEDIATRIC ASSOCIATES, INC.
Entity Type:Organization
Organization Name:SOUTHERN ORANGE COUNTY PEDIATRIC ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-770-6789
Mailing Address - Street 1:23321 EL TORO RD
Mailing Address - Street 2:SUITES F&G
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-4825
Mailing Address - Country:US
Mailing Address - Phone:949-770-6789
Mailing Address - Fax:949-829-9125
Practice Address - Street 1:23321 EL TORO RD
Practice Address - Street 2:SUITES F&G
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-4825
Practice Address - Country:US
Practice Address - Phone:949-770-6789
Practice Address - Fax:949-829-9125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-07
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty