Healthcare Provider Details

I. General information

NPI: 1265361802
Provider Name (Legal Business Name): MR. MICHAEL TERRY WIMPIE II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 MORENA BLVD STE 100
SAN DIEGO CA
92110-3850
US

IV. Provider business mailing address

1260 MORENA BLVD
SAN DIEGO CA
92110-3889
US

V. Phone/Fax

Practice location:
  • Phone: 619-398-0355
  • Fax:
Mailing address:
  • Phone: 619-398-0355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-RGUKSI
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: