Healthcare Provider Details

I. General information

NPI: 1326131079
Provider Name (Legal Business Name): VALLE VERDE PEDIATRICS MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 01/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15525 POMERADO ROAD #B1
POWAY CA
92064-2465
US

IV. Provider business mailing address

15525 POMERADO ROAD #B1
POWAY CA
92064-2465
US

V. Phone/Fax

Practice location:
  • Phone: 858-487-8333
  • Fax: 858-487-0856
Mailing address:
  • Phone: 858-487-8333
  • Fax: 858-487-0856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number00G642310
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberFNP18257
License Number StateCA

VIII. Authorized Official

Name: DR. NATHAN RENDLER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 858-487-8333