Healthcare Provider Details

I. General information

NPI: 1336531516
Provider Name (Legal Business Name): INTEGRATIVE CARDIOVASCULAR CENTER OF LA JOLLA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2015
Last Update Date: 03/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9834 GENESEE AVE STE 101
LA JOLLA CA
92037-1223
US

IV. Provider business mailing address

PO BOX 2552
CHULA VISTA CA
91912-2552
US

V. Phone/Fax

Practice location:
  • Phone: 858-430-8455
  • Fax: 619-934-3268
Mailing address:
  • Phone: 858-430-8455
  • Fax: 619-934-3268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: VITALI AIZIN
Title or Position: MD
Credential:
Phone: 858-430-8455