=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285880047
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANTA CLARA PEDIATRIC CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2008
-----------------------------------------------------
Last Update Date | 08/13/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7524 KENNEDY BLVD
-----------------------------------------------------
City | NORTH BERGEN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07047-4037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-758-0290
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7524 KENNEDY BLVD
-----------------------------------------------------
City | NORTH BERGEN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07047-4037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-758-0290
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICINE DOCTOR
-----------------------------------------------------
Name | DAMARIS ALEJANDRA EGUINO CONDE
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 201-758-0290
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 25MA08433000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------