Provider Demographics
NPI:1194587964
Name:PEDIACLINIC LLC
Entity type:Organization
Organization Name:PEDIACLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:FEITEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-981-1494
Mailing Address - Street 1:9555 S UNIVERSITY BLVD UNIT 102
Mailing Address - Street 2:
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80126-8114
Mailing Address - Country:US
Mailing Address - Phone:303-302-3879
Mailing Address - Fax:
Practice Address - Street 1:7505 E 35TH AVE UNIT 360
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80238-2463
Practice Address - Country:US
Practice Address - Phone:303-302-3879
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIACLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-01-26
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1851866180OtherNPPES
CO179794Medicaid