Basic Information
| Provider Information | |||||||||
| NPI: | 1710196886 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HUNTINGTON BEACH UNION HIGH SCHOOL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5832 BOLSA AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926491115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149037000 | ||||||||
| FaxNumber: | 7143728102 | ||||||||
| Practice Location | |||||||||
| Address1: | 5832 BOLSA AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926491115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149037000 | ||||||||
| FaxNumber: | 7143728102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOFFMAN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PUPIL PERSONNEL SERVICE | ||||||||
| AuthorizedOfficialTelephone: | 7149037000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251300000X | Y | Agencies | Local Education Agency (LEA) |
ID Information
| ID | Type | State | Issuer | Description | SS3066548 | 05 | CA | MEDICAID |