Healthcare Provider Details

I. General information

NPI: 1063532661
Provider Name (Legal Business Name): JUAN JR. OLMEDA CDI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3851 ROSECRANS ST
SAN DIEGO CA
92110-3115
US

IV. Provider business mailing address

3851 ROSECRANS ST
SAN DIEGO CA
92110-3115
US

V. Phone/Fax

Practice location:
  • Phone: 619-692-5639
  • Fax: 619-692-8821
Mailing address:
  • Phone: 619-692-5639
  • Fax: 619-692-8821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: