Provider Demographics
NPI:1538304134
Name:ASPEN PEDIATRIC CLINIC,INC.
Entity type:Organization
Organization Name:ASPEN PEDIATRIC CLINIC,INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCELINO
Authorized Official - Middle Name:S
Authorized Official - Last Name:CALIMLIM
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:760-951-9985
Mailing Address - Street 1:15203 11TH ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-3737
Mailing Address - Country:US
Mailing Address - Phone:760-951-9985
Mailing Address - Fax:760-952-3387
Practice Address - Street 1:15203 11TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-3737
Practice Address - Country:US
Practice Address - Phone:760-951-9985
Practice Address - Fax:760-952-3387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-10
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79537208000000X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A795370Medicaid