Healthcare Provider Details

I. General information

NPI: 1164319463
Provider Name (Legal Business Name): IMPERIAL COUNTY PEDIATRIC ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2025
Last Update Date: 06/19/2025
Certification Date: 06/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 WAKE AVE
EL CENTRO CA
92243-7502
US

IV. Provider business mailing address

6 VERANDA
NEWPORT COAST CA
92657-1632
US

V. Phone/Fax

Practice location:
  • Phone: 760-352-7216
  • Fax:
Mailing address:
  • Phone: 818-399-8996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: MS. LAN NHU BICH PHAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 626-656-2370