Basic Information
| Provider Information | |||||||||
| NPI: | 1649562422 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 3853 ROSECRANS ST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3853 ROSECRANS ST | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196928222 | ||||||||
| FaxNumber: | 6196925734 | ||||||||
| Practice Location | |||||||||
| Address1: | 3853 ROSECRANS ST | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921103115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196928222 | ||||||||
| FaxNumber: | 6196925734 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2011 | ||||||||
| LastUpdateDate: | 05/11/2011 | ||||||||
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| AuthorizedOfficialLastName: | CASTRO | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | LPT | ||||||||
| AuthorizedOfficialTelephone: | 6926928222 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | PT23671 | CA | Y | Hospitals | Psychiatric Hospital |
No ID Information.