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General NPI Number Information
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NPI Number | 1356656664
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Entity Type | Organization
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Legal Business Name | PEDIATRIC PARTNERS MEDICAL PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 08/11/2010
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Last Update Date | 08/11/2010
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Provider Practice Location Address
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Address Line | 1111 N CHINA LAKE BLVD SUITE 120
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City | RIDGECREST
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State | CA
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Zip | 93555-3131
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Country | US
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Telephone | 760-446-7337
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Fax | 760-446-7338
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Provider Business Mailing Address
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Address Line | 27699 JEFFERSON AVE SUITE 300
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City | TEMECULA
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State | CA
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Zip | 92590-2661
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Country | US
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Telephone | 951-252-8588
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Fax | 951-252-8589
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Authorized Official
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Title or Position | CHIEF OPERATIONS OFFICER
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Name | CHERYL FUCHIGAMI-BOST, RN
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Credential | RN
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Telephone | 951-252-8588
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080A0000X
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Taxonomy Name | Pediatric Adolescent Medicine Physician
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License Number | 0900009973
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License Number State | CA
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