1437664315 NPI number — CHRISTINA BOONTANOND

Table of content: CHRISTINA BOONTANOND (NPI 1437664315)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437664315 NPI number — CHRISTINA BOONTANOND

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOONTANOND
Provider First Name:
CHRISTINA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1437664315
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5150 E PACIFIC COAST HWY STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90804-3394
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-490-7600
Provider Business Mailing Address Fax Number:
562-490-7601

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12912 BROOKHURST ST STE 480
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARDEN GROVE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92840-4867
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-636-6286
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/13/2017

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: 106H00000X , with the licence number:  101118 , 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)