1881736320 NPI number — SUSAN HARTLEY HORIUCHI OD

Table of content: MERCEDES HENLEY RDH (NPI 1649405408)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881736320 NPI number — SUSAN HARTLEY HORIUCHI OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HORIUCHI
Provider First Name:
SUSAN
Provider Middle Name:
HARTLEY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HARTLEY
Provider Other First Name:
SUSAN
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1881736320
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 PARK AVE STE 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAGUNA BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92651-2352
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-494-2546
Provider Business Mailing Address Fax Number:
949-497-0010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 PARK AVE STE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAGUNA BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92651-2352
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-494-2546
Provider Business Practice Location Address Fax Number:
949-497-0010
Provider Enumeration Date:
02/13/2007

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: 152W00000X , with the licence number:  7484T , 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: SD0074840 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0180480001 . This is a "CMS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: OP7484 CA . This is a "MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 0180480001 . This is a "DMERC REGION D" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 0182880001 . This is a "MEDICARE NSC" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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