Provider Demographics
NPI:1700646288
Name:THE PEDIATRIC & ADOLESCENTS CLINIC INC.
Entity type:Organization
Organization Name:THE PEDIATRIC & ADOLESCENTS CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DINA
Authorized Official - Middle Name:D
Authorized Official - Last Name:DOMALANTA-VILLALUNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:671-647-7337
Mailing Address - Street 1:415 CHALAN SAN ANTONIO STE 109
Mailing Address - Street 2:
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913-3620
Mailing Address - Country:US
Mailing Address - Phone:671-647-7337
Mailing Address - Fax:671-647-7336
Practice Address - Street 1:415 CHALAN SAN ANTONIO STE 109
Practice Address - Street 2:
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-3620
Practice Address - Country:US
Practice Address - Phone:671-647-7337
Practice Address - Fax:671-647-7336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty