MEDICARE: SGBA DIVERSIFIED INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	97888	CA

General Provider Information

NPI Number	:	1538669163
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SGBA DIVERSIFIED INC

Provider Business Mailing Address
First Line	:	5735 KEARNY VILLA RD STE 101
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-1138
Country	:	US
Telephone Number	:	619-644-2170
Fax Number	:	619-644-2174

Provider Business Practice Location Address
First Line	:	5735 KEARNY VILLA RD STE 101
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-1138
Country	:	US
Telephone Number	:	619-644-2170
Fax Number	:	619-644-2174

Authorized Official
Title or Position	:	PRESIDENT
Name	:	STEPHEN J GRISWOLD
Credential	:
Telephone Number	:	619-644-2170

Provider Enumeration Date	:	02/20/2018
Last Update Date	:	02/20/2018

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