Healthcare Provider Details

I. General information

NPI: 1326378100
Provider Name (Legal Business Name): RISE MEDICAL CENTER A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2009
Last Update Date: 01/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5030 BONITA RD SUITE B
BONITA CA
91902-1700
US

IV. Provider business mailing address

5030 BONITA RD SUITE B
BONITA CA
91902-1700
US

V. Phone/Fax

Practice location:
  • Phone: 619-479-7473
  • Fax: 619-479-9376
Mailing address:
  • Phone: 619-479-7473
  • Fax: 619-479-9376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC28449
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA73257
License Number StateCA

VIII. Authorized Official

Name: DR. JOSE CANDELARIO
Title or Position: OWNER
Credential:
Phone: 619-479-7473