Basic Information
| Provider Information | |||||||||
| NPI: | 1639449994 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RADY CHILDREN'S HOSPITAL - SAN DIEGO | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KIDSTART CENTRAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3020 CHILDRENS WAY | ||||||||
| Address2: | MC 5134 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921234223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589665990 | ||||||||
| FaxNumber: | 8589667508 | ||||||||
| Practice Location | |||||||||
| Address1: | 3665 KEARNY VILLA RD | ||||||||
| Address2: | SUITE 405 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921231953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589665990 | ||||||||
| FaxNumber: | 8589667508 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2012 | ||||||||
| LastUpdateDate: | 01/04/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8589665814 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC2000X | 080000028 | CA | Y | Hospitals | General Acute Care Hospital | Children |
No ID Information.