Provider Demographics
NPI:1134691124
Name:SOCAL BEHAVIORAL MEDICINE, INC.
Entity type:Organization
Organization Name:SOCAL BEHAVIORAL MEDICINE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GINGER
Authorized Official - Middle Name:
Authorized Official - Last Name:HULST
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:310-698-5252
Mailing Address - Street 1:10650 REAGAN ST UNIT 824
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-8844
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1711 VIA EL PRADO STE 301
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-5723
Practice Address - Country:US
Practice Address - Phone:310-698-5252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
No163WP0000XNursing Service ProvidersRegistered NursePain ManagementGroup - Multi-Specialty
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, AdultGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty