1174645360 NPI number — MRS. JUSTINE OCONNELL BACKHAUS LM,CPM

Table of content: MRS. JUSTINE OCONNELL BACKHAUS LM,CPM (NPI 1174645360)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174645360 NPI number — MRS. JUSTINE OCONNELL BACKHAUS LM,CPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BACKHAUS
Provider First Name:
JUSTINE
Provider Middle Name:
OCONNELL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LM,CPM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OHTA
Provider Other First Name:
JUSTINE
Provider Other Middle Name:
OCONNELL
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
LM,CPM
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174645360
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23801 COYOTE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEHACHAPI
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93561-9213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
661-821-0659
Provider Business Mailing Address Fax Number:
661-821-0659

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23801 COYOTE CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEHACHAPI
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93561-9213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-821-0659
Provider Business Practice Location Address Fax Number:
661-821-0659
Provider Enumeration Date:
04/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 176B00000X , with the licence number:  LM185 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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