Healthcare Provider Details

I. General information

NPI: 1881728954
Provider Name (Legal Business Name): PUENTE DE VIDA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3013 WOODFORD DR
LA JOLLA CA
92037-3549
US

IV. Provider business mailing address

PO BOX 86020
SAN DIEGO CA
92138-6020
US

V. Phone/Fax

Practice location:
  • Phone: 858-452-3915
  • Fax: 858-452-1798
Mailing address:
  • Phone: 858-452-3915
  • Fax: 858-452-1798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number StateCA

VIII. Authorized Official

Name: MR. STEPHEN E. SCHAEFER
Title or Position: PRESIDENT
Credential: L.C.S.W.
Phone: 858-452-3915