Healthcare Provider Details

I. General information

NPI: 1952865198
Provider Name (Legal Business Name): INDUSTRIAL CARE SPECIALIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2019
Last Update Date: 01/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5565 GROSSMONT CENTER DR STE 259
LA MESA CA
91942-3098
US

IV. Provider business mailing address

PO BOX 33
PORT HUENEME CA
93044-0033
US

V. Phone/Fax

Practice location:
  • Phone: 619-315-0336
  • Fax: 619-315-0338
Mailing address:
  • Phone: 619-202-6970
  • Fax: 619-202-6971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: CATHIE BACON
Title or Position: BILLING MANAGER
Credential:
Phone: 619-202-6970