Basic Information
| Provider Information | |||||||||
| NPI: | 1669472510 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SD SPORTS MEDICINE AND FAMILY HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6699 ALVARADO RD | ||||||||
| Address2: | STE 2100 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921205238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192293909 | ||||||||
| FaxNumber: | 6192293902 | ||||||||
| Practice Location | |||||||||
| Address1: | 6699 ALVARADO RD | ||||||||
| Address2: | STE 2100 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921205238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192293909 | ||||||||
| FaxNumber: | 6192293902 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2005 | ||||||||
| LastUpdateDate: | 10/03/2017 | ||||||||
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| AuthorizedOfficialLastName: | PARKER | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT / CEO | ||||||||
| AuthorizedOfficialTelephone: | 6192293909 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | GR0064940 | 05 | CA | MEDICAID | W12026 | 01 | CA | GROUP PTAN | OTHER |