1760578538 NPI number — MS. LUANN SUE BEACOM N.P.

Table of content: MS. LUANN SUE BEACOM N.P. (NPI 1760578538)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760578538 NPI number — MS. LUANN SUE BEACOM N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEACOM
Provider First Name:
LUANN
Provider Middle Name:
SUE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
N.P.
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:
1760578538
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5383 BOTHE AVE
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:
92122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-546-9088
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4060 4TH AVE
Provider Second Line Business Practice Location Address:
SUITE 420
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-299-3111
Provider Business Practice Location Address Fax Number:
619-299-3126
Provider Enumeration Date:
10/05/2006

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: 363L00000X , with the licence number:  9876 , 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)

  • Identifier: 249 . This is a "CLIN. NURSE SPEC CERT #" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 9876 . This is a "N.P. FURNISHING #" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: RN336125 . This is a "R.N. LICENSE #" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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