Healthcare Provider Details

I. General information

NPI: 1215622071
Provider Name (Legal Business Name): RANCHO BERNARDO HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2023
Last Update Date: 04/07/2023
Certification Date: 04/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3750 CONVOY ST STE 220
SAN DIEGO CA
92111-3741
US

IV. Provider business mailing address

3750 CONVOY ST STE 220
SAN DIEGO CA
92111-3741
US

V. Phone/Fax

Practice location:
  • Phone: 619-452-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: LEE JOHNSON
Title or Position: TREASURER
Credential:
Phone: 208-401-1369