Healthcare Provider Details

I. General information

NPI: 1952538050
Provider Name (Legal Business Name): MS. SARINA RENAE TIDWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 06/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5005 TEXAS ST STE 203
SAN DIEGO CA
92108-3723
US

IV. Provider business mailing address

5990 DANDRIDGE LN UNIT 191
SAN DIEGO CA
92115-6579
US

V. Phone/Fax

Practice location:
  • Phone: 619-692-0727
  • Fax:
Mailing address:
  • Phone: 408-781-5876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: