MEDICARE: GWENDOLYN MARIE HAMILTON RADT1

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	324500000X	Substance Abuse Rehabilitation Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	324500000X	OTHER	CA	THE WAY BACK

General Provider Information

NPI Number	:	1790241180
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GWENDOLYN MARIE HAMILTON RADT1

Provider Business Mailing Address
First Line	:	2516 A ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92102-2111
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2516 A ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92102-2111
Country	:	US
Telephone Number	:	619-235-0592
Fax Number	:

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

Provider Enumeration Date	:	02/11/2019
Last Update Date	:	02/11/2019

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