Healthcare Provider Details

I. General information

NPI: 1639210958
Provider Name (Legal Business Name): KILEY SAN MARTIN CADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7200 PARKWAY DR SUITE 113
LA MESA CA
91942-1534
US

IV. Provider business mailing address

7200 PARKWAY DR SUITE 113
LA MESA CA
91942-1534
US

V. Phone/Fax

Practice location:
  • Phone: 619-589-0552
  • Fax: 619-589-0205
Mailing address:
  • Phone: 619-589-0552
  • Fax: 619-589-0205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberA8402702
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: