Provider Demographics
NPI:1982879722
Name:HOLLISTER PEDIATRICS
Entity Type:Organization
Organization Name:HOLLISTER PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-630-1477
Mailing Address - Street 1:930 SUNNYSLOPE RD
Mailing Address - Street 2:SUITE E-2
Mailing Address - City:HOLLISTER
Mailing Address - State:CA
Mailing Address - Zip Code:95023-5615
Mailing Address - Country:US
Mailing Address - Phone:831-630-1477
Mailing Address - Fax:831-630-1531
Practice Address - Street 1:930 SUNNYSLOPE RD
Practice Address - Street 2:SUITE E-2
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023-5615
Practice Address - Country:US
Practice Address - Phone:831-630-1477
Practice Address - Fax:831-630-1531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20AX7593208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX75930Medicaid