Provider Demographics
NPI:1568154623
Name:HAALBOOM, JOHN RICHARD JR
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RICHARD
Last Name:HAALBOOM
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43250 MIDNIGHT CT
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-9565
Mailing Address - Country:US
Mailing Address - Phone:951-922-1725
Mailing Address - Fax:
Practice Address - Street 1:43250 MIDNIGHT CT
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-9565
Practice Address - Country:US
Practice Address - Phone:951-922-1725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist