Healthcare Provider Details

I. General information

NPI: 1881810042
Provider Name (Legal Business Name): PEDIATRIC RESOURCE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1479 YGNACIO VALLEY RD SUITE 208
WALNUT CREEK CA
94598-2986
US

IV. Provider business mailing address

PO BOX 1350
SUISUN CITY CA
94585-4350
US

V. Phone/Fax

Practice location:
  • Phone: 925-634-9704
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MICHAEL SINCLAIR
Title or Position: PRESIDENT
Credential: MD
Phone: 925-634-9704