Basic Information
| Provider Information | |||||||||
| NPI: | 1033198916 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHARP MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SHARP HOME HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8695 SPECTRUM CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921231489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584993025 | ||||||||
| FaxNumber: | 8584994738 | ||||||||
| Practice Location | |||||||||
| Address1: | 8080 DAGGET ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921112333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589394850 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 03/07/2019 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8589394082 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SHARP MEMORIAL HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 080000039 | CA | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | HHA70159F | 05 | CA | MEDICAID |