Healthcare Provider Details

I. General information

NPI: 1952499378
Provider Name (Legal Business Name): FOOTHILL PEDIATRIC & ADOLESCENT CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 10/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 W COVINA BLVD SUITE 106
SAN DIMAS CA
91773
US

IV. Provider business mailing address

1330 W COVINA BLVD SUITE 106
SAN DIMAS CA
91773
US

V. Phone/Fax

Practice location:
  • Phone: 909-599-6876
  • Fax: 909-592-9787
Mailing address:
  • Phone: 909-599-6876
  • Fax: 909-592-9787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. GEORGE M MADANAT
Title or Position: PRESIDENT
Credential: MD
Phone: 909-599-6876