MEDICARE: KIDS FIRST PEDIATRIC CLINIC LLC

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	208000000X	Pediatrics Physician	MD28575	OR

General Provider Information

NPI Number	:	1902144298
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDS FIRST PEDIATRIC CLINIC LLC

Provider Business Mailing Address
First Line	:	18603 WILLAMETTE DR
Second Line	:
City	:	WEST LINN
State	:	OR
Zip	:	97068-1705
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	18603 WILLAMETTE DR
Second Line	:
City	:	WEST LINN
State	:	OR
Zip	:	97068-1705
Country	:	US
Telephone Number	:	503-730-1634
Fax Number	:

Authorized Official
Title or Position	:	OWNER/MD
Name	:	BADIA JABBOUR
Credential	:	MD
Telephone Number	:	503-730-1634

Provider Enumeration Date	:	01/22/2013
Last Update Date	:	01/22/2013

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