Basic Information
| Provider Information | |||||||||
| NPI: | 1982703831 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VA HOSPITAL SAN DIEGO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3350 LA JOLLA VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920371806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585528585 | ||||||||
| FaxNumber: | 6196423119 | ||||||||
| Practice Location | |||||||||
| Address1: | 3550 LAJOLLA VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921610001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585528585 | ||||||||
| FaxNumber: | 6196423119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FALLS | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
| AuthorizedOfficialMiddleName: | KEVIN | ||||||||
| AuthorizedOfficialTitleorPosition: | MHICM CASE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8585528585 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | I | ||||||||
| AuthorizedOfficialCredential: | RN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | 343025 | CA | X | Agencies | Case Management | 282N00000X | 343026 | CA | X | Hospitals | General Acute Care Hospital | 313M00000X | 343026 | CA | X | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
No ID Information.