Healthcare Provider Details

I. General information

NPI: 1275546095
Provider Name (Legal Business Name): PEDIATRIC MEDICAL ASSOCIATES OF TRI-CITY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2067 W VISTA WAY SUITE 180
VISTA CA
92083-6031
US

IV. Provider business mailing address

2067 W VISTA WAY SUITE 180
VISTA CA
92083-6031
US

V. Phone/Fax

Practice location:
  • Phone: 760-945-3434
  • Fax: 760-945-6761
Mailing address:
  • Phone: 760-945-3434
  • Fax: 760-945-6761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JEANNINE EDWARDS
Title or Position: ADMINISTRATOR
Credential:
Phone: 760-945-3434