MEDICARE: IMPERIAL COUNTY PEDIATRIC ASSOCIATES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	302F00000X	Exclusive Provider Organization

General Provider Information

NPI Number	:	1164319463
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPERIAL COUNTY PEDIATRIC ASSOCIATES, INC.

Provider Business Mailing Address
First Line	:	6 VERANDA
Second Line	:
City	:	NEWPORT COAST
State	:	CA
Zip	:	92657-1632
Country	:	US
Telephone Number	:	818-399-8996
Fax Number	:

Provider Business Practice Location Address
First Line	:	702 WAKE AVE
Second Line	:
City	:	EL CENTRO
State	:	CA
Zip	:	92243-7502
Country	:	US
Telephone Number	:	760-352-7216
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. LAN NHU BICH PHAN
Credential	:
Telephone Number	:	626-656-2370

Provider Enumeration Date	:	06/19/2025
Last Update Date	:	04/20/2026

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