Healthcare Provider Details

I. General information

NPI: 1043854078
Provider Name (Legal Business Name): BRIAN DAVID EVELAND SUDCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2019
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

737 E GRAND AVE
ESCONDIDO CA
92025-4404
US

IV. Provider business mailing address

737 E GRAND AVE
ESCONDIDO CA
92025-4404
US

V. Phone/Fax

Practice location:
  • Phone: 760-745-9485
  • Fax: 760-745-6852
Mailing address:
  • Phone: 760-745-9485
  • Fax: 760-745-6852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberR1361190819
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: