Healthcare Provider Details

I. General information

NPI: 1790850279
Provider Name (Legal Business Name): PEDIATRIC SUBSPECIALTY FACULTY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 W LA VETA AVE
ORANGE CA
92868-4203
US

IV. Provider business mailing address

455 S MAIN ST
ORANGE CA
92868-3835
US

V. Phone/Fax

Practice location:
  • Phone: 714-509-8649
  • Fax: 714-509-8374
Mailing address:
  • Phone: 715-094-8649
  • Fax: 714-509-8374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateCA

VIII. Authorized Official

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