Basic Information
| Provider Information | |||||||||
| NPI: | 1467502971 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SEQUOIA PEDIATRIC ORTHOPAEDICS MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1187 N WILLOW AVE STE 103 | ||||||||
| Address2: | PMB#17 | ||||||||
| City: | CLOVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936114411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593247300 | ||||||||
| FaxNumber: | 5593247350 | ||||||||
| Practice Location | |||||||||
| Address1: | 9300 VALLEY CHILDRENS PL | ||||||||
| Address2: | #FE10 | ||||||||
| City: | MADERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936388761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593535944 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HENNRIKUS | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | LAWRENCE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5593247300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XP3100X | A41574 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | GR0085690 | 05 | CA | MEDICAID | ZZZ60690Z | 01 | CA | BLUE CROSS & BLUE SHIELD | OTHER |