Healthcare Provider Details

I. General information

NPI: 1619301082
Provider Name (Legal Business Name): SELENE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2013
Last Update Date: 08/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

374 N COAST HIGHWAY 101 STE F12
ENCINITAS CA
92024-2542
US

IV. Provider business mailing address

374 N COAST HIGHWAY 101 STE F12
ENCINITAS CA
92024-2542
US

V. Phone/Fax

Practice location:
  • Phone: 760-525-0117
  • Fax: 760-436-1608
Mailing address:
  • Phone: 760-525-0117
  • Fax: 760-436-1608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateCA

VIII. Authorized Official

Name: HEATHER PIERSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 760-525-0117