Healthcare Provider Details

I. General information

NPI: 1720271059
Provider Name (Legal Business Name): PEDIATRIC AND ASTHMA CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2007
Last Update Date: 08/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 CHALAN SAN ANTONIO P & F PROFESSIONAL MANOR SUITE 101
TAMUNING GU
96913
US

IV. Provider business mailing address

428 CHALAN SAN ANTONIO P & F PROFESSIONAL MANOR SUITE 101
TAMUNING GU
96913
US

V. Phone/Fax

Practice location:
  • Phone: 671-647-4121
  • Fax: 671-646-4429
Mailing address:
  • Phone: 671-647-4121
  • Fax: 671-646-4429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: EDGARDO C HIDALGO
Title or Position: PRESIDENT
Credential: MD
Phone: 671-647-4121