1538304134 NPI number — ASPEN PEDIATRIC CLINIC,INC.

Table of content: (NPI 1538304134)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538304134 NPI number — ASPEN PEDIATRIC CLINIC,INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ASPEN PEDIATRIC CLINIC,INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538304134
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15203 11TH ST
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
VICTORVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92395-3737
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-951-9985
Provider Business Mailing Address Fax Number:
760-952-3387

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15203 11TH ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
VICTORVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92395-3737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-951-9985
Provider Business Practice Location Address Fax Number:
760-952-3387
Provider Enumeration Date:
12/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CALIMLIM
Authorized Official First Name:
MARCELINO
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
760-951-9985

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  A79537 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X , with the licence number: A79537 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00A795370 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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