Healthcare Provider Details

I. General information

NPI: 1326653999
Provider Name (Legal Business Name): PUMPHREY PATCH KIDZ, A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2020
Last Update Date: 09/10/2020
Certification Date: 09/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29798 HAUN RD STE 304
MENIFEE CA
92586-6542
US

IV. Provider business mailing address

29798 HAUN RD STE 304
MENIFEE CA
92586-6542
US

V. Phone/Fax

Practice location:
  • Phone: 951-679-3159
  • Fax: 951-679-0250
Mailing address:
  • Phone: 951-679-3159
  • Fax: 951-679-0250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KATHRYN SPAAN
Title or Position: MANAGER
Credential:
Phone: 951-679-3159