Basic Information
| Provider Information | |||||||||
| NPI: | 1386753655 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAN DIEGO HEALTH ALLIANCE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EL CAJON TREATMENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6185 PASEO DEL NORTE, STE 150 | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920111155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552592288 | ||||||||
| FaxNumber: | 6195798155 | ||||||||
| Practice Location | |||||||||
| Address1: | 234 N MAGNOLIA AVE | ||||||||
| Address2: | |||||||||
| City: | EL CAJON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920203906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195798378 | ||||||||
| FaxNumber: | 6195798155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 03/12/2020 | ||||||||
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| AuthorizedOfficialLastName: | SANDERSON | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT CTC DIVISION | ||||||||
| AuthorizedOfficialTelephone: | 8552592288 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | 37-09 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
No ID Information.