Healthcare Provider Details

I. General information

NPI: 1962542159
Provider Name (Legal Business Name): LAGUNA HILLS PEDIATRIC MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24953 PASEO DE VALENCIA #5A
LAGUNA HILLS CA
92653-4342
US

IV. Provider business mailing address

24953 PASEO DE VALENCIA #5A
LAGUNA HILLS CA
92653-4342
US

V. Phone/Fax

Practice location:
  • Phone: 949-951-1376
  • Fax: 949-951-6378
Mailing address:
  • Phone: 949-951-1376
  • Fax: 949-951-6378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG320830
License Number StateCA

VIII. Authorized Official

Name: DR. DENNIS S PHILLIPS
Title or Position: PRESIDENT
Credential: MD
Phone: 949-951-1376