Basic Information
| Provider Information | |||||||||
| NPI: | 1851866180 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIACLINIC LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9094 E MINERAL AVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | CENTENNIAL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036943200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9555 SOUTH UNIVERSITY BLVD | ||||||||
| Address2: | UNIT B-2 | ||||||||
| City: | HIGHLANDS RANCH | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033023879 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2018 | ||||||||
| LastUpdateDate: | 10/13/2018 | ||||||||
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| AuthorizedOfficialLastName: | FEITEN | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | JAMES | ||||||||
| AuthorizedOfficialTitleorPosition: | BOARD MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3039811494 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.