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General NPI Number Information
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NPI Number | 1871871624
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Entity Type | Organization
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Legal Business Name | CENTRAL CALIFORNIA PEDIATRIC SPECIALTY MEDICAL GROUP INC
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Dates
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Enumeration Date | 07/28/2011
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Last Update Date | 01/26/2017
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Provider Practice Location Address
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Address Line | 400 W MINERAL KING AVE
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City | VISALIA
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State | CA
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Zip | 93291-6237
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Country | US
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Telephone | 559-280-9165
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Fax | 559-635-2696
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Provider Business Mailing Address
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Address Line | 5940 W BUENA VISTA CT
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City | VISALIA
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State | CA
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Zip | 93291-9173
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Country | US
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Telephone | 559-280-9165
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Fax | 559-635-2696
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Authorized Official
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Title or Position | CFO
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Name | DR. ANA CAROLINA COLL
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Credential | M.D
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Telephone | 559-280-9165
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | A69432
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | A69635
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License Number State | CA
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