Healthcare Provider Details

I. General information

NPI: 1770146086
Provider Name (Legal Business Name): KEN J HINE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2019
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 SOQUEL DR
SANTA CRUZ CA
95065-1794
US

IV. Provider business mailing address

11455 ASTER ST APT 1/2
LOMA LINDA CA
92354-3401
US

V. Phone/Fax

Practice location:
  • Phone: 831-462-7700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA180141
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: