Healthcare Provider Details

I. General information

NPI: 1073816583
Provider Name (Legal Business Name): LACEE MARIE CHILDERS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LACEE MARIE MARSHALL PA

II. Dates (important events)

Enumeration Date: 12/06/2010
Last Update Date: 09/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4445 MAGNOLIA AVE
RIVERSIDE CA
92501-4135
US

IV. Provider business mailing address

PO BOX 79495
CORONA CA
92877-0183
US

V. Phone/Fax

Practice location:
  • Phone: 951-788-3200
  • Fax: 951-788-3200
Mailing address:
  • Phone: 951-788-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA21251
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: