Healthcare Provider Details

I. General information

NPI: 1386987915
Provider Name (Legal Business Name): COMMUNITY ELDERCARE SAN DIEGO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2013
Last Update Date: 04/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 ELM ST
SAN DIEGO CA
92101-2692
US

IV. Provider business mailing address

111 ELM ST
SAN DIEGO CA
92101-2692
US

V. Phone/Fax

Practice location:
  • Phone: 619-677-3800
  • Fax: 619-781-8186
Mailing address:
  • Phone: 619-677-3800
  • Fax: 619-781-8186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number550001964
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number StateCA

VIII. Authorized Official

Name: MRS. AMANDA JOY GOIS
Title or Position: MARKETING DIRECTOR
Credential:
Phone: 619-677-3800