Healthcare Provider Details

I. General information

NPI: 1356710495
Provider Name (Legal Business Name): LEAH BOTIMER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2015
Last Update Date: 09/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E REDLANDS BLVD
REDLANDS CA
92373-4775
US

IV. Provider business mailing address

101 E REDLANDS BLVD
REDLANDS CA
92373-4775
US

V. Phone/Fax

Practice location:
  • Phone: 909-792-8866
  • Fax: 909-792-9395
Mailing address:
  • Phone: 909-792-8866
  • Fax: 909-792-9395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberNP95002812
License Number StateCA

VIII. Authorized Official

Name: ALLISON EALY BLACKWELL
Title or Position: ASSITANT
Credential:
Phone: 909-792-8866