Healthcare Provider Details

I. General information

NPI: 1417760364
Provider Name (Legal Business Name): FIDARE HEALTH CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2025
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3434 GROVE ST
LEMON GROVE CA
91945-1812
US

IV. Provider business mailing address

2358 UNIVERSITY AVE STE 371
SAN DIEGO CA
92104-2720
US

V. Phone/Fax

Practice location:
  • Phone: 619-782-0011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JONATHON WHEATON
Title or Position: AUTHORIZED OFFICER
Credential:
Phone: 619-782-0011