Basic Information
Provider Information | |||||||||
NPI: | 1659464410 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COUNTY OF SAN DIEGO | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6160 MISSION GORGE RD. | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 92120 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6195284000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 510 E. NAPLES ST. | ||||||||
Address2: | RM 28 | ||||||||
City: | CHULA VISTA | ||||||||
State: | CA | ||||||||
PostalCode: | 91911 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6194216083 | ||||||||
FaxNumber: | 6194828284 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/02/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BURNS | ||||||||
AuthorizedOfficialFirstName: | ROBYN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF | ||||||||
AuthorizedOfficialTelephone: | 6195284082 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302F00000X | CCS00039F | CA | Y |   | Managed Care Organizations | Exclusive Provider Organization |   |
ID Information
ID | Type | State | Issuer | Description | CCS00039F | 01 | CA | MEDI-CAL PROVIDER NUMBER | OTHER |