Basic Information
| Provider Information | |||||||||
| NPI: | 1275694184 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VALLEY CHILDREN'S HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | IP MEDI-CAL & MCCS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9300 VALLEY CHILDRENS PL | ||||||||
| Address2: | |||||||||
| City: | MADERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936368762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593533000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9300 VALLEY CHILDRENS PL | ||||||||
| Address2: | |||||||||
| City: | MADERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936368762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593533000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 05/04/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WALDRON | ||||||||
| AuthorizedOfficialFirstName: | MICHELE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SVP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 5593533000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC2000X | 040000160 | CA | Y | Hospitals | General Acute Care Hospital | Children |
ID Information
| ID | Type | State | Issuer | Description | HSC00130F | 05 | CA | MEDICAID |