Healthcare Provider Details

I. General information

NPI: 1003054420
Provider Name (Legal Business Name): PEDIATRIC SUBSPECIALTY FACULTY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2009
Last Update Date: 10/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 S MAIN ST GENERAL SURGERY
ORANGE CA
92868-3835
US

IV. Provider business mailing address

455 S MAIN ST GENERAL SURGERY
ORANGE CA
92868-3835
US

V. Phone/Fax

Practice location:
  • Phone: 714-364-4050
  • Fax: 714-364-4051
Mailing address:
  • Phone: 714-364-4050
  • Fax: 714-364-4051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: HALE KUHLMAN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 714-289-4511