Healthcare Provider Details

I. General information

NPI: 1699220004
Provider Name (Legal Business Name): SAN DIEGO PROFESSIONAL GROUP, P. C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2016
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24552 PACIFIC PARK DR
ALISO VIEJO CA
92656-3033
US

IV. Provider business mailing address

200 POWELL PL ATTN: LEGAL DEPARTMENT
BRENTWOOD TN
37027-7514
US

V. Phone/Fax

Practice location:
  • Phone: 615-727-8416
  • Fax: 615-457-8094
Mailing address:
  • Phone: 615-732-1605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number20A6119
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number20A6119
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number20A6119
License Number StateCA

VIII. Authorized Official

Name: MARK CALARCO
Title or Position: FACILITY CEO
Credential: DO
Phone: 615-712-5862