Healthcare Provider Details

I. General information

NPI: 1669934055
Provider Name (Legal Business Name): A FRIEND FOR LIFE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 03/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

928 FORT STOCKTON DR STE 205
SAN DIEGO CA
92103-1893
US

IV. Provider business mailing address

928 FORT STOCKTON DR STE 205
SAN DIEGO CA
92103-1893
US

V. Phone/Fax

Practice location:
  • Phone: 619-450-4686
  • Fax: 619-450-4689
Mailing address:
  • Phone: 619-450-4686
  • Fax: 619-450-4689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID WALLACE
Title or Position: OPERATING MEMBER
Credential:
Phone: 619-450-4686