Provider Demographics
NPI:1174916779
Name:BEACHKIDS PEDIATRICS A PROFESSIONAL NURSING CORPORATION
Entity type:Organization
Organization Name:BEACHKIDS PEDIATRICS A PROFESSIONAL NURSING CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:CANGIALOSI
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:310-697-6833
Mailing Address - Street 1:918 EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-3261
Mailing Address - Country:US
Mailing Address - Phone:310-697-6833
Mailing Address - Fax:848-210-9648
Practice Address - Street 1:918 EMERALD ST
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3261
Practice Address - Country:US
Practice Address - Phone:310-697-6833
Practice Address - Fax:848-210-9648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-06
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9281363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty