Healthcare Provider Details

I. General information

NPI: 1326101502
Provider Name (Legal Business Name): SERVICE INTERNATIONAL,INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 E GRAND AVE SUITE A
ESCONDIDO CA
92025-4460
US

IV. Provider business mailing address

120 NEPTUNE PL
ESCONDIDO CA
92026-2076
US

V. Phone/Fax

Practice location:
  • Phone: 760-738-7008
  • Fax:
Mailing address:
  • Phone: 760-739-1949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberAC 6841
License Number StateCA

VIII. Authorized Official

Name: MR. CONRADO EBREO CASTRO JR.
Title or Position: PRESIDENT
Credential:
Phone: 760-738-7008