Provider Demographics
NPI:1699905927
Name:EDGEWOOD PEDIATRIC CLINIC L.L.C.
Entity type:Organization
Organization Name:EDGEWOOD PEDIATRIC CLINIC L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:GARNAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-281-4620
Mailing Address - Street 1:PO BOX 1320
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:NM
Mailing Address - Zip Code:87015-1320
Mailing Address - Country:US
Mailing Address - Phone:505-281-4620
Mailing Address - Fax:505-281-0397
Practice Address - Street 1:2 EUNICE CT BLDG B
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:NM
Practice Address - Zip Code:87015-9108
Practice Address - Country:US
Practice Address - Phone:505-281-4620
Practice Address - Fax:505-281-0397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-21
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2003-0092208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty