Healthcare Provider Details

I. General information

NPI: 1700646288
Provider Name (Legal Business Name): THE PEDIATRIC & ADOLESCENTS CLINIC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2024
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 CHALAN SAN ANTONIO STE 109
TAMUNING GU
96913-3620
US

IV. Provider business mailing address

415 CHALAN SAN ANTONIO STE 109
TAMUNING GU
96913-3620
US

V. Phone/Fax

Practice location:
  • Phone: 671-647-7337
  • Fax: 671-647-7336
Mailing address:
  • Phone: 671-647-7337
  • Fax: 671-647-7336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DINA D DOMALANTA-VILLALUNA
Title or Position: PRESIDENT
Credential: MD
Phone: 671-647-7337