Healthcare Provider Details

I. General information

NPI: 1285945535
Provider Name (Legal Business Name): CHILDRENS CRITICAL CARE OF VENTURA COUNTY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2010
Last Update Date: 07/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3291 LOMA VISTA RD
VENTURA CA
93003-3099
US

IV. Provider business mailing address

3116 W MARCH LN SUITE 200
STOCKTON CA
95219-2369
US

V. Phone/Fax

Practice location:
  • Phone: 805-652-6000
  • Fax:
Mailing address:
  • Phone: 209-473-6555
  • Fax: 209-473-6544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License NumberA75408
License Number StateCA

VIII. Authorized Official

Name: JOHN W. MARCUM
Title or Position: PRESIDENT
Credential: MD
Phone: 805-338-2395