Healthcare Provider Details

I. General information

NPI: 1720176845
Provider Name (Legal Business Name): PEDIATRIC PARTNERS MEDICAL PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 12/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3989 W STETSON AVE
HEMET CA
92545-9695
US

IV. Provider business mailing address

27699 JEFFERSON AVE SUITE 300
TEMECULA CA
92590-2661
US

V. Phone/Fax

Practice location:
  • Phone: 951-765-7002
  • Fax: 866-390-9162
Mailing address:
  • Phone: 951-252-8588
  • Fax: 951-252-8589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: THOMAS P MOHR
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: M.D.
Phone: 951-252-8588