Basic Information
| Provider Information | |||||||||
| NPI: | 1841241585 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PSYCHIATRIC CENTERS AT SAN DIEGO, INC. MED GRP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 609001 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921609001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195284600 | ||||||||
| FaxNumber: | 6195284625 | ||||||||
| Practice Location | |||||||||
| Address1: | 4542 RUFFNER ST | ||||||||
| Address2: | SUITE#200 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921112237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195284600 | ||||||||
| FaxNumber: | 6195284625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 01/11/2022 | ||||||||
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| AuthorizedOfficialLastName: | MORACHE | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6195284600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 01/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.