Healthcare Provider Details

I. General information

NPI: 1629332044
Provider Name (Legal Business Name): PDIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2012
Last Update Date: 06/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21155 FLAMETREE
LAKE FOREST CA
92630-6721
US

IV. Provider business mailing address

21155 FLAMETREE
LAKE FOREST CA
92630-6721
US

V. Phone/Fax

Practice location:
  • Phone: 949-289-1530
  • Fax:
Mailing address:
  • Phone: 949-289-1530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number090017351
License Number StateCA

VIII. Authorized Official

Name: AJA MCKEE
Title or Position: PRESIDENT
Credential: M.S., ED.S.
Phone: 949-289-1530