Healthcare Provider Details

I. General information

NPI: 1649717737
Provider Name (Legal Business Name): LA JOLLA ANESTHESIA ASSOCIATES LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2017
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9850 GENESEE AVE SUITE 980
LA JOLLA CA
92037-1224
US

IV. Provider business mailing address

1A BURTON HILLS BLVD ATTN: PROVIDER ENROLLMENT
NASHVILLE TN
37215-6187
US

V. Phone/Fax

Practice location:
  • Phone: 858-453-7525
  • Fax:
Mailing address:
  • Phone: 615-240-3809
  • Fax: 615-234-1809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: PHILLIP CLENDENIN
Title or Position: PRESIDENT
Credential:
Phone: 615-665-1283