1023676848 NPI number — CANDACE LEAH BURINGRUD RADT-I

Table of content: CANDACE LEAH BURINGRUD RADT-I (NPI 1023676848)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023676848 NPI number — CANDACE LEAH BURINGRUD RADT-I

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURINGRUD
Provider First Name:
CANDACE
Provider Middle Name:
LEAH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RADT-I
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:
1023676848
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1701 MISSION AVE STE 310
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCEANSIDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92058-7110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-721-2781
Provider Business Mailing Address Fax Number:
760-712-3195

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 N JOHNSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL CAJON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92020-1650
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-721-2781
Provider Business Practice Location Address Fax Number:
760-712-3195
Provider Enumeration Date:
06/05/2019

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: 101YA0400X , with the licence number:  R1368101019 , 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)