Basic Information
| Provider Information | |||||||||
| NPI: | 1770944027 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOME AVENUE CTC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3940 HOME AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921055952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192828000 | ||||||||
| FaxNumber: | 6197189897 | ||||||||
| Practice Location | |||||||||
| Address1: | 3940 HOME AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921055952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192828000 | ||||||||
| FaxNumber: | 6197189897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2016 | ||||||||
| LastUpdateDate: | 03/15/2016 | ||||||||
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| AuthorizedOfficialLastName: | GACHUPIN | ||||||||
| AuthorizedOfficialFirstName: | KRISTAL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AOD COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 6192828000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CATC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | C0502041556 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
ID Information
| ID | Type | State | Issuer | Description | C0502041556 | 01 | CA | CCAPP | OTHER |