Basic Information
| Provider Information | |||||||||
| NPI: | 1861482002 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALING | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | LEROY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 339 | ||||||||
| Address2: | |||||||||
| City: | MOUNT SHASTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960670339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309265613 | ||||||||
| FaxNumber: | 5309268798 | ||||||||
| Practice Location | |||||||||
| Address1: | 824 PINE ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT SHASTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960672137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309264528 | ||||||||
| FaxNumber: | 5309265070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2005 | ||||||||
| LastUpdateDate: | 03/21/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | C28244 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 00C282440 | 05 | CA | MEDICAID |