Healthcare Provider Details

I. General information

NPI: 1588752612
Provider Name (Legal Business Name): PEDIATRIC PARTNERS MEDICAL PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 05/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36320 INLAND VALLEY DR SUITE 203
WILDOMAR CA
92595-7512
US

IV. Provider business mailing address

27699 JEFFERSON AVE SUITE 300
TEMECULA CA
92590-2661
US

V. Phone/Fax

Practice location:
  • Phone: 951-200-2220
  • Fax: 951-200-2221
Mailing address:
  • Phone: 951-252-8588
  • Fax: 951-252-8589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: THOMAS P MOHR
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: M.D.
Phone: 951-252-8588