Provider Demographics
NPI:1669775730
Name:EUREKA PEDIATRICS MEDICAL PRACTICE
Entity type:Organization
Organization Name:EUREKA PEDIATRICS MEDICAL PRACTICE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELESHA
Authorized Official - Middle Name:L
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-445-9413
Mailing Address - Street 1:2800 HARRIS ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95503-4809
Mailing Address - Country:US
Mailing Address - Phone:707-445-9413
Mailing Address - Fax:707-445-4182
Practice Address - Street 1:2192 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MCKINLEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95519-3610
Practice Address - Country:US
Practice Address - Phone:707-839-3377
Practice Address - Fax:707-839-3612
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EUREKA PEDIATRICS MEDICAL PRACTICE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-13
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA553849OtherRURAL HEALTH NUMBER