1235784968 NPI number — GLEN F PASTORES

Table of content: (NPI 1235784968)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235784968 NPI number — GLEN F PASTORES

Organization/Personal Information

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

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:
1235784968
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1761 HOTEL CIR S STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92108-3318
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-987-4848
Provider Business Mailing Address Fax Number:
858-987-4849

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1761 HOTEL CIR S STE 380
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92108-3318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-987-4848
Provider Business Practice Location Address Fax Number:
858-987-4849
Provider Enumeration Date:
08/08/2019

Additional Information

Authorized Official

Authorized Official Last Name:
PASTORES
Authorized Official First Name:
GLEN
Authorized Official Middle Name:
F
Authorized Official Title or Position:
OWNER/LMFT
Authorized Official Telephone Number:
858-987-4848

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: LMFT94162 . This is a "STATE OF CALIFORNIA BOARD OF BEHAVIORAL SCIENCES" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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