Healthcare Provider Details

I. General information

NPI: 1457587677
Provider Name (Legal Business Name): RADY CHILDREN HOSPITAL AND HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2009
Last Update Date: 06/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1261 3RD AVE D
CHULA VISTA CA
91911-3262
US

IV. Provider business mailing address

1261 3RD AVE D
CHULA VISTA CA
91911-3262
US

V. Phone/Fax

Practice location:
  • Phone: 619-420-5611
  • Fax: 619-420-5531
Mailing address:
  • Phone: 619-420-5611
  • Fax: 619-420-5531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License NumberASW16491
License Number StateCA

VIII. Authorized Official

Name: MRS. MARIA P CLARK
Title or Position: SOCIAL WORKER 1
Credential: MSW
Phone: 619-420-5611