Provider Demographics
NPI:1356710495
Name:LEAH BOTIMER
Entity type:Organization
Organization Name:LEAH BOTIMER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSITANT
Authorized Official - Prefix:
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:EALY
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-792-8866
Mailing Address - Street 1:101 E REDLANDS BLVD
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4775
Mailing Address - Country:US
Mailing Address - Phone:909-792-8866
Mailing Address - Fax:909-792-9395
Practice Address - Street 1:101 E REDLANDS BLVD
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4775
Practice Address - Country:US
Practice Address - Phone:909-792-8866
Practice Address - Fax:909-792-9395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-18
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95002812208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP95002812OtherNP LICENSE