Healthcare Provider Details

I. General information

NPI: 1619152402
Provider Name (Legal Business Name): PACIFIC COAST PEDIATRIC CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2007
Last Update Date: 01/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

252 GREEN VALLEY RD
FREEDOM CA
95019-3138
US

IV. Provider business mailing address

252 GREEN VALLEY RD
FREEDOM CA
95019-3138
US

V. Phone/Fax

Practice location:
  • Phone: 831-722-0272
  • Fax: 831-722-1007
Mailing address:
  • Phone: 831-722-0272
  • Fax: 831-722-1007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. LINDA LEE SHAW
Title or Position: OWNER, PARTNER, SECY-TREAS
Credential: MD
Phone: 831-722-0272