Healthcare Provider Details

I. General information

NPI: 1992899942
Provider Name (Legal Business Name): PEDIATRIC & ADOLESCENT MEDICAL ASSOC. OF THE PACIFIC COAST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 09/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 SAN JOSE ST
SALINAS CA
93901-3901
US

IV. Provider business mailing address

260 SAN JOSE ST
SALINAS CA
93901-3901
US

V. Phone/Fax

Practice location:
  • Phone: 831-757-8124
  • Fax: 731-757-4790
Mailing address:
  • Phone: 831-757-8124
  • Fax: 731-757-4790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. CONNIE K. KELLOUGH
Title or Position: CAO
Credential:
Phone: 831-757-8124