Healthcare Provider Details

I. General information

NPI: 1457841777
Provider Name (Legal Business Name): HEALTHY AGING CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

Provider Other Name: GAMEDAY MEN'S HEALTH

II. Dates (important events)

Enumeration Date: 05/11/2018
Last Update Date: 12/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2753 JEFFERSON ST STE 204
CARLSBAD CA
92008-1704
US

IV. Provider business mailing address

2753 JEFFERSON ST STE 204
CARLSBAD CA
92008-1704
US

V. Phone/Fax

Practice location:
  • Phone: 949-542-9717
  • Fax:
Mailing address:
  • Phone: 858-252-9202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: K MITCHELL NAFICY
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 858-252-9202