Basic Information
| Provider Information | |||||||||
| NPI: | 1669775730 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EUREKA PEDIATRICS MEDICAL PRACTICE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EUREKA PEDIATRICS MCKINLEYVILLE OFFICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2800 HARRIS ST | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955034809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074459413 | ||||||||
| FaxNumber: | 7074454182 | ||||||||
| Practice Location | |||||||||
| Address1: | 2192 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | MCKINLEYVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955193610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078393377 | ||||||||
| FaxNumber: | 7078393612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2010 | ||||||||
| LastUpdateDate: | 04/06/2011 | ||||||||
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| AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | ELESHA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7074459413 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EUREKA PEDIATRICS MEDICAL PRACTICE | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 553849 | 01 | CA | RURAL HEALTH NUMBER | OTHER |