Healthcare Provider Details

I. General information

NPI: 1194974972
Provider Name (Legal Business Name): THE CHILDREN'S DOCTOR PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2008
Last Update Date: 09/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3975 JACKSON ST SUITE 207
RIVERSIDE CA
92503-3901
US

IV. Provider business mailing address

3975 JACKSON ST SUITE 207
RIVERSIDE CA
92503-3901
US

V. Phone/Fax

Practice location:
  • Phone: 951-352-2092
  • Fax: 951-352-1913
Mailing address:
  • Phone: 951-352-2092
  • Fax: 951-352-1913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA79434
License Number StateCA

VIII. Authorized Official

Name: JUDITH M BEDOY
Title or Position: DIRECTOR
Credential:
Phone: 951-352-2092