1063797488 NPI number — MR. JOHANNES HENDRIKUS SCHOTHORST JR. LAC

Table of content: MR. JOHANNES HENDRIKUS SCHOTHORST JR. LAC (NPI 1063797488)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063797488 NPI number — MR. JOHANNES HENDRIKUS SCHOTHORST JR. LAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCHOTHORST
Provider First Name:
JOHANNES
Provider Middle Name:
HENDRIKUS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
LAC
Provider Gender Code:
M

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:
1063797488
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13252 GARDEN GROVE BLVD STE 112
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARDEN GROVE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92843-2270
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-740-1778
Provider Business Mailing Address Fax Number:
714-740-1918

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13252 GARDEN GROVE BLVD STE 112
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:
92843-2270
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-740-1778
Provider Business Practice Location Address Fax Number:
714-740-1918
Provider Enumeration Date:
10/17/2011

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: 171100000X , with the licence number:  14054 , 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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