=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689860108
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARMEL VALLEY PEDIATRICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2007
-----------------------------------------------------
Last Update Date | 09/18/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12395 EL CAMINO REAL SUITE 315
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92130-3082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-794-5437
-----------------------------------------------------
Fax | 858-794-5439
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12395 EL CAMINO REAL SUITE 315
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92130-3082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-794-5437
-----------------------------------------------------
Fax | 858-794-5439
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CHRYSTAL DE FREITAS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 858-794-5437
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | C50161
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------