Healthcare Provider Details

I. General information

NPI: 1275864910
Provider Name (Legal Business Name): ABC CHILDREN'S CLINIC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2010
Last Update Date: 09/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26730 TOWNE CENTRE DR SUITE 102
FOOTHILL RANCH CA
92610-2842
US

IV. Provider business mailing address

26730 TOWNE CENTRE DR SUITE 102
FOOTHILL RANCH CA
92610-2842
US

V. Phone/Fax

Practice location:
  • Phone: 949-380-1234
  • Fax: 949-305-2230
Mailing address:
  • Phone: 949-380-1234
  • Fax: 949-305-2230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG078954
License Number StateCA

VIII. Authorized Official

Name: DR. MARJAN MONFARED
Title or Position: PRESIDENT
Credential: M.D.
Phone: 949-380-1234