Healthcare Provider Details

I. General information

NPI: 1851659197
Provider Name (Legal Business Name): COLLEGE HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2012
Last Update Date: 04/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4560 COLLEGE AVE
SAN DIEGO CA
92115-4012
US

IV. Provider business mailing address

4560 COLLEGE AVE
SAN DIEGO CA
92115-4012
US

V. Phone/Fax

Practice location:
  • Phone: 619-948-5323
  • Fax:
Mailing address:
  • Phone: 619-948-5323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number31479
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number31965
License Number StateCA

VIII. Authorized Official

Name: DR. DANNY B BACHOUA
Title or Position: CHIROPRACTOR/OWNER
Credential: DC
Phone: 619-948-5323