Provider Demographics
NPI:1225501380
Name:PEDACE, CAROLINA
Entity type:Individual
Prefix:MRS
First Name:CAROLINA
Middle Name:
Last Name:PEDACE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:CAROLINA
Other - Middle Name:
Other - Last Name:LUJAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:27261 LAS RAMBLAS STE 220
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6468
Mailing Address - Country:US
Mailing Address - Phone:909-980-6700
Mailing Address - Fax:
Practice Address - Street 1:9500 HAVEN AVE STE 100
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5871
Practice Address - Country:US
Practice Address - Phone:909-980-6700
Practice Address - Fax:909-557-2146
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-10
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 372600000X
CAMPSS-GPIVQ175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No172V00000XOther Service ProvidersCommunity Health Worker
No372600000XNursing Service Related ProvidersAdult Companion