MEDICARE: TLC PEDIATRICS MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist		CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356303168
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TLC PEDIATRICS MEDICAL GROUP

Provider Business Mailing Address
First Line	:	30210 RANCHO VIEJO RD
Second Line	:	SUITE A
City	:	SAN JUAN CAPISTRANO
State	:	CA
Zip	:	92675-1574
Country	:	US
Telephone Number	:	949-493-7337
Fax Number	:	949-493-1418

Provider Business Practice Location Address
First Line	:	30210 RANCHO VIEJO RD
Second Line	:	SUITE A
City	:	SAN JUAN CAPISTRANO
State	:	CA
Zip	:	92675-1574
Country	:	US
Telephone Number	:	949-493-7337
Fax Number	:	949-493-1418

Authorized Official
Title or Position	:	MEDICAL MANAGER
Name	:	JOSIANE SUZANNE DAGOSTINO
Credential	:	CMM
Telephone Number	:	949-493-1383

Provider Enumeration Date	:	04/05/2006
Last Update Date	:	07/21/2022

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