Provider Demographics
NPI:1952499378
Name:FOOTHILL PEDIATRIC & ADOLESCENT CLINIC
Entity Type:Organization
Organization Name:FOOTHILL PEDIATRIC & ADOLESCENT CLINIC
Other - Org Name:GEORGE M MADANAT M INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MADANAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-599-6876
Mailing Address - Street 1:1330 W COVINA BLVD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773
Mailing Address - Country:US
Mailing Address - Phone:909-599-6876
Mailing Address - Fax:909-592-9787
Practice Address - Street 1:1330 W COVINA BLVD
Practice Address - Street 2:SUITE 106
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773
Practice Address - Country:US
Practice Address - Phone:909-599-6876
Practice Address - Fax:909-592-9787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty