Provider Demographics
NPI:1790858124
Name:VALLEY PEDIATRIC MEDICAL GROUP,INC.
Entity type:Organization
Organization Name:VALLEY PEDIATRIC MEDICAL GROUP,INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KARYN
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-789-7181
Mailing Address - Street 1:5353 BALBOA BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-2804
Mailing Address - Country:US
Mailing Address - Phone:818-789-7181
Mailing Address - Fax:818-986-8322
Practice Address - Street 1:5353 BALBOA BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-2804
Practice Address - Country:US
Practice Address - Phone:818-789-7181
Practice Address - Fax:818-986-8322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty