Healthcare Provider Details

I. General information

NPI: 1982511242
Provider Name (Legal Business Name): COSA SAN DIEGO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 SEACOAST DR APT 11
IMPERIAL BEACH CA
91932-3131
US

IV. Provider business mailing address

1112 SEACOAST DR APT 9
IMPERIAL BEACH CA
91932-3131
US

V. Phone/Fax

Practice location:
  • Phone: 503-318-5438
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. THOMAS CORNWELL
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 619-871-4924