Healthcare Provider Details

I. General information

NPI: 1639152820
Provider Name (Legal Business Name): CHILDRENS CARDIAC MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 07/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W HUNTINGTON DR #415
ARCADIA CA
91007-3462
US

IV. Provider business mailing address

301 W HUNTINGTON DR #415
ARCADIA CA
91007-3462
US

V. Phone/Fax

Practice location:
  • Phone: 626-445-5552
  • Fax: 626-445-4411
Mailing address:
  • Phone: 626-445-5552
  • Fax: 626-445-4411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberG12458
License Number StateCA

VIII. Authorized Official

Name: L STEPHEN GORDON
Title or Position: OWNER
Credential: M.D.
Phone: 626-445-5552