Basic Information
| Provider Information | |||||||||
| NPI: | 1205053956 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RADY CHILDRENS HOSPITAL OF SAN DIEGO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1659 COUNTRYSIDE DR | ||||||||
| Address2: | |||||||||
| City: | VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920818725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607341629 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3142 VISTA WAY | ||||||||
| Address2: | |||||||||
| City: | OCEANSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920563619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609677082 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | AGCAYAB | ||||||||
| AuthorizedOfficialFirstName: | VIRGINIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | SITE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7609677082 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | MFT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
No ID Information.