=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679083513
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHRISTABELLE CO MD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2017
-----------------------------------------------------
Last Update Date | 06/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 161 S SPRUCE AVE STE 205
-----------------------------------------------------
City | SOUTH SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94080-4517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-808-9848
-----------------------------------------------------
Fax | 650-808-9848
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 161 S SPRUCE AVE STE 205
-----------------------------------------------------
City | SOUTH SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94080-4517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-808-9848
-----------------------------------------------------
Fax | 650-808-9848
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CORPORATE OWNER/PRESIDENT
-----------------------------------------------------
Name | CHRISTABELLE CO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 650-808-9858
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | A148358
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------