Basic Information
| Provider Information | |||||||||
| NPI: | 1891826434 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STARK | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RAS #S0906221308 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4283 EL CAJON BLVD STE 115 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921051289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195211743 | ||||||||
| FaxNumber: | 6195211896 | ||||||||
| Practice Location | |||||||||
| Address1: | 4283 EL CAJON BLVD STE 115 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921051289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195211743 | ||||||||
| FaxNumber: | 6195211896 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 12/02/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | RAS #S0906221308 | CA | Y | Other Service Providers | Case Manager/Care Coordinator | 101YA0400X | RAS #S0906221308 | CA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.