Healthcare Provider Details

I. General information

NPI: 1184796583
Provider Name (Legal Business Name): MARILOU C ENCARNACION PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PEPPER AVE DEPARTMENT OF PEDIATRICS
COLTON CA
92324-1818
US

IV. Provider business mailing address

400 NORTH PEPPER AVE 6TH FLOOR ADMINISTRATIVE OFFICE PEDIAT
COLTON CA
92324-1819
US

V. Phone/Fax

Practice location:
  • Phone: 909-580-6315
  • Fax: 909-580-6361
Mailing address:
  • Phone: 909-580-6315
  • Fax: 909-580-6361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number16126
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: