MEDICARE: MR. JOSEPH D. THORNELL RRW

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	R1109	CA

General Provider Information

NPI Number	:	1568685071
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOSEPH D. THORNELL RRW

Provider Business Mailing Address
First Line	:	2645 BALBOA VISTA DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92105-5022
Country	:	US
Telephone Number	:	619-262-1931
Fax Number	:

Provider Business Practice Location Address
First Line	:	1161 3RD AVE
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91911-3136
Country	:	US
Telephone Number	:	619-498-8260
Fax Number	:	619-498-8265

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/11/2007
Last Update Date	:	07/08/2007

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