Basic Information
| Provider Information | |||||||||
| NPI: | 1700989829 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN DIEGO HEALTH ALLIANCE | ||||||||
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| OtherOrganizationName: | FASHION VALLEY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6185 PASEO DEL NORTE | ||||||||
| Address2: | STE 150 | ||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920111155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552592288 | ||||||||
| FaxNumber: | 6197189897 | ||||||||
| Practice Location | |||||||||
| Address1: | 7545 METROPOLITAN DR | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921084402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6197189890 | ||||||||
| FaxNumber: | 6197189897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 01/15/2020 | ||||||||
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| AuthorizedOfficialLastName: | SANDERSON | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | INTERIM PRESIDENT, CTC DIVISION | ||||||||
| AuthorizedOfficialTelephone: | 8552592288 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ACADIA HEALTHCARE COMPANY, INC. | ||||||||
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| NPICertificationDate: | 01/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 37-15 | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QM2800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
No ID Information.