Healthcare Provider Details

I. General information

NPI: 1063927770
Provider Name (Legal Business Name): HUMBOLDT PEDIATRIC MEDICAL CORPORATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2017
Last Update Date: 12/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2192 CENTRAL AVE STE A
MCKINLEYVILLE CA
95519-3610
US

IV. Provider business mailing address

1011 FRESHWATER RD
EUREKA CA
95503-9457
US

V. Phone/Fax

Practice location:
  • Phone: 707-839-1000
  • Fax: 707-839-1400
Mailing address:
  • Phone: 707-599-0642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA64795
License Number StateCA

VIII. Authorized Official

Name: DR. SARAH BERTRAM POYEN
Title or Position: MD
Credential: MD
Phone: 707-599-0642