Healthcare Provider Details

I. General information

NPI: 1710254040
Provider Name (Legal Business Name): JUMPSTART PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2011
Last Update Date: 12/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2828 S BRETT ST
GILBERT AZ
85295-6016
US

IV. Provider business mailing address

10875 KEMAH LN
SAN DIEGO CA
92131-1320
US

V. Phone/Fax

Practice location:
  • Phone: 480-710-5590
  • Fax: 858-693-1367
Mailing address:
  • Phone: 619-977-1614
  • Fax: 858-693-1367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number947393 (CMO)
License Number StateAZ

VIII. Authorized Official

Name: MR. LOWELL W GIFFHORN
Title or Position: PRESIDENT
Credential:
Phone: 619-977-1614