Healthcare Provider Details

I. General information

NPI: 1497821441
Provider Name (Legal Business Name): PEDIATRIC ACUTE CARE MEDICAL ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 10/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5353 BALBOA BLVD SUITE 201
ENCINO CA
91316-2804
US

IV. Provider business mailing address

PO BOX 571027
TARZANA CA
91357-1027
US

V. Phone/Fax

Practice location:
  • Phone: 818-788-5437
  • Fax: 818-788-5436
Mailing address:
  • Phone: 818-788-5437
  • Fax: 818-788-5436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA47742
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberA47742
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberA47742
License Number StateCA

VIII. Authorized Official

Name: DR. CARMEN JULIA BOTERO
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 818-788-5437