Basic Information
Provider Information | |||||||||
NPI: | 1104573633 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE BEACON HOUSE ASSOCIATION OF SAN PEDRO | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 328 | ||||||||
Address2: |   | ||||||||
City: | SAN PEDRO | ||||||||
State: | CA | ||||||||
PostalCode: | 907330328 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3105144940 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 103 W. 11TH ST. | ||||||||
Address2: |   | ||||||||
City: | SAN PEDRO | ||||||||
State: | CA | ||||||||
PostalCode: | 907314301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3105144940 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/04/2022 | ||||||||
LastUpdateDate: | 03/04/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HIGGINS | ||||||||
AuthorizedOfficialFirstName: | JONATHAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | COMPLIANCE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 3105144940 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CATC NO. 2013751 | ||||||||
NPICertificationDate: | 02/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.