Basic Information
| Provider Information | |||||||||
| NPI: | 1801989405 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF SAN DIEGO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6160 MISSION GORGE ROAD | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195284000 | ||||||||
| FaxNumber: | 6195284077 | ||||||||
| Practice Location | |||||||||
| Address1: | 1609 E. MADISON AVE. | ||||||||
| Address2: | |||||||||
| City: | EL CAJON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195883145 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BURNS | ||||||||
| AuthorizedOfficialFirstName: | ROBYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 6195284082 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302F00000X | CCS00038F | CA | Y | Managed Care Organizations | Exclusive Provider Organization |
ID Information
| ID | Type | State | Issuer | Description | CCS00038F | 01 | CA | MEDI-CAL PROVIDER NUMBER | OTHER |