Healthcare Provider Details

I. General information

NPI: 1417907940
Provider Name (Legal Business Name): LPCH MEDICAL GROUP DIV OF LUCILE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 08/12/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 WELCH RD
PALO ALTO CA
94304-1601
US

IV. Provider business mailing address

4700 BOHANNON DR MC 5530
MENLO PARK CA
94025-1031
US

V. Phone/Fax

Practice location:
  • Phone: 650-498-6762
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DANA JEAN HAERING
Title or Position: CFO
Credential:
Phone: 650-721-2222