Healthcare Provider Details

I. General information

NPI: 1649066911
Provider Name (Legal Business Name): MICHAEL LA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2025
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 GILMAN DR DEPT 304
LA JOLLA CA
92093-0304
US

IV. Provider business mailing address

2235 DEL MAR SCENIC PKWY
DEL MAR CA
92014-3633
US

V. Phone/Fax

Practice location:
  • Phone: 858-534-3755
  • Fax:
Mailing address:
  • Phone: 858-210-0688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: