Healthcare Provider Details

I. General information

NPI: 1497847305
Provider Name (Legal Business Name): TRI-VALLEY NEONATAL MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 02/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15107 VANOWEN ST
VAN NUYS CA
91405-4542
US

IV. Provider business mailing address

PO BOX 1359
SAN CLEMENTE CA
92674-1359
US

V. Phone/Fax

Practice location:
  • Phone: 818-902-2978
  • Fax:
Mailing address:
  • Phone: 949-492-3514
  • Fax: 949-366-2390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KARA NORDBERG
Title or Position: ACCOUNTS ADMINISTRATOR
Credential:
Phone: 949-492-3514