=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710254040
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JUMPSTART PEDIATRICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2011
-----------------------------------------------------
Last Update Date | 12/01/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2828 S BRETT ST
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85295-6016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-710-5590
-----------------------------------------------------
Fax | 858-693-1367
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10875 KEMAH LN
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92131-1320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-977-1614
-----------------------------------------------------
Fax | 858-693-1367
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. LOWELL W GIFFHORN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 619-977-1614
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 947393 (CMO)
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------