MEDICARE: SD SPORTS MEDICINE AND FAMILY HEALTH CENTER

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	261QM1300X	Multi-Specialty Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	W12026	OTHER	CA	GROUP PTAN

General Provider Information

NPI Number	:	1669472510
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SD SPORTS MEDICINE AND FAMILY HEALTH CENTER

Provider Business Mailing Address
First Line	:	6699 ALVARADO RD
Second Line	:	STE 2100
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-5238
Country	:	US
Telephone Number	:	619-229-3909
Fax Number	:	619-229-3902

Provider Business Practice Location Address
First Line	:	6699 ALVARADO RD
Second Line	:	STE 2100
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-5238
Country	:	US
Telephone Number	:	619-229-3909
Fax Number	:	619-229-3902

Authorized Official
Title or Position	:	PRESIDENT / CEO
Name	:	DR. RICHARD A. PARKER
Credential	:	D.O.
Telephone Number	:	619-229-3909

Provider Enumeration Date	:	07/21/2005
Last Update Date	:	10/03/2017

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Directions to “SD SPORTS MEDICINE AND FAMILY HEALTH CENTER ” Practice Location

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