Healthcare Provider Details

I. General information

NPI: 1427773662
Provider Name (Legal Business Name): PEDIATRIC PREFERRED CHOICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2022
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4821 LANKERSHIM BLVD STE FPMB1029
NORTH HOLLYWOOD CA
91601-4538
US

IV. Provider business mailing address

4821 LANKERSHIM BLVD STE FPMB1029
NORTH HOLLYWOOD CA
91601-4538
US

V. Phone/Fax

Practice location:
  • Phone: 424-303-1031
  • Fax:
Mailing address:
  • Phone: 424-303-1031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: THADDEUS TERRELL WELCH
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 424-303-1031