Healthcare Provider Details

I. General information

NPI: 1285256115
Provider Name (Legal Business Name): TERESA VIDMAR RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2020
Last Update Date: 09/01/2024
Certification Date: 09/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 CRESTA LOMA
ESCONDIDO CA
92025-7778
US

IV. Provider business mailing address

5065 MOUNT LA PLATTA DR
SAN DIEGO CA
92117-3007
US

V. Phone/Fax

Practice location:
  • Phone: 530-219-7248
  • Fax:
Mailing address:
  • Phone: 530-219-7248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number80800
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number391318
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: