Healthcare Provider Details

I. General information

NPI: 1962826685
Provider Name (Legal Business Name): SEASIDE NURSING ANESTHESIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2014
Last Update Date: 02/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 GENTER ST UNIT 404
LA JOLLA CA
92037-5530
US

IV. Provider business mailing address

935 GENTER ST UNIT 404
LA JOLLA CA
92037-5530
US

V. Phone/Fax

Practice location:
  • Phone: 858-337-3179
  • Fax:
Mailing address:
  • Phone: 858-337-3179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4125
License Number StateCA

VIII. Authorized Official

Name: KIM ROINESTAD HARBIN
Title or Position: OWNER
Credential: CRNA
Phone: 858-337-3179