Provider Demographics
NPI:1447536321
Name:MADRONA PEDIATRICS, A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:MADRONA PEDIATRICS, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:YEN FU
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:LIU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-534-3231
Mailing Address - Street 1:3250 SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-2719
Mailing Address - Country:US
Mailing Address - Phone:310-534-3231
Mailing Address - Fax:310-667-8779
Practice Address - Street 1:3250 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-2719
Practice Address - Country:US
Practice Address - Phone:310-534-3231
Practice Address - Fax:310-667-8779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA97572261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center