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General NPI Number Information
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NPI Number | 1992965750
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Entity Type | Organization
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Legal Business Name | PEDIATRIC HEALTH CARE
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Dates
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Enumeration Date | 06/13/2008
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Last Update Date | 06/13/2008
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Provider Practice Location Address
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Address Line | 120 14TH AVE SE STE A
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City | PUYALLUP
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State | WA
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Zip | 98372-3718
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Country | US
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Telephone | 253-848-7660
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Fax | 253-841-1801
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Provider Business Mailing Address
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Address Line | 120 14TH AVE SE STE A
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City | PUYALLUP
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State | WA
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Zip | 98372-3718
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Country | US
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Telephone | 253-848-7660
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Fax | 253-841-1801
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Authorized Official
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Title or Position | MANGER
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Name | DR. MAZEN DAHAN
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Credential | M.D.
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Telephone | 253-848-7660
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | 025209 MD00038984
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License Number State | WA
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