Healthcare Provider Details

I. General information

NPI: 1306098652
Provider Name (Legal Business Name): PEDIATRIC SUBSPECIALTY FACULTY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2008
Last Update Date: 05/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 S MAIN ST
ORANGE CA
92868-3835
US

IV. Provider business mailing address

455 S MAIN ST
ORANGE CA
92868-3835
US

V. Phone/Fax

Practice location:
  • Phone: 714-633-4020
  • Fax: 714-953-5462
Mailing address:
  • Phone: 714-633-4020
  • Fax: 714-953-5462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License NumberA54475
License Number StateCA

VIII. Authorized Official

Name: HALE KUHLMAN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 714-532-8649