Provider Demographics
NPI:1013966670
Name:KIDS DOC OF SOUTHERN CALIFORNIA MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:KIDS DOC OF SOUTHERN CALIFORNIA MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:MARY ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-951-5437
Mailing Address - Street 1:27800 MEDICAL CENTER RD SUITE 204
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691
Mailing Address - Country:US
Mailing Address - Phone:949-682-4750
Mailing Address - Fax:949-682-4751
Practice Address - Street 1:27800 MEDICAL CENTER RD SUITE 204
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691
Practice Address - Country:US
Practice Address - Phone:949-682-4750
Practice Address - Fax:949-682-4751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX ID NUMBER