Healthcare Provider Details

I. General information

NPI: 1023930260
Provider Name (Legal Business Name): RICHARD ELDEN HOSTUTLER III LVN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

892 27TH ST
SAN DIEGO CA
92154-1444
US

IV. Provider business mailing address

358 E SAN YSIDRO BLVD STE 181
SAN DIEGO CA
92173-2722
US

V. Phone/Fax

Practice location:
  • Phone: 619-575-4687
  • Fax:
Mailing address:
  • Phone: 619-882-9550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number267004
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: