Healthcare Provider Details

I. General information

NPI: 1356656664
Provider Name (Legal Business Name): PEDIATRIC PARTNERS MEDICAL PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2010
Last Update Date: 08/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 N CHINA LAKE BLVD SUITE 120
RIDGECREST CA
93555-3131
US

IV. Provider business mailing address

27699 JEFFERSON AVE SUITE 300
TEMECULA CA
92590-2661
US

V. Phone/Fax

Practice location:
  • Phone: 760-446-7337
  • Fax: 760-446-7338
Mailing address:
  • Phone: 951-252-8588
  • Fax: 951-252-8589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number0900009973
License Number StateCA

VIII. Authorized Official

Name: CHERYL FUCHIGAMI-BOST, RN
Title or Position: CHIEF OPERATIONS OFFICER
Credential: RN
Phone: 951-252-8588