Healthcare Provider Details

I. General information

NPI: 1629554803
Provider Name (Legal Business Name): GERALD R SHIREY III CADC-II, ICADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2018
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9909 HUENNEKENS ST STE 110
SAN DIEGO CA
92121-2928
US

IV. Provider business mailing address

1777 BUCKMAN SPRINGS RD
CAMPO CA
91906-2022
US

V. Phone/Fax

Practice location:
  • Phone: 858-500-8000
  • Fax: 858-624-1429
Mailing address:
  • Phone: 619-478-5696
  • Fax: 619-478-2404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: