Healthcare Provider Details

I. General information

NPI: 1003663410
Provider Name (Legal Business Name): VILLA OASIS SAN DIEGO IOP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2024
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16516 BERNARDO CENTER DR STE 130
SAN DIEGO CA
92128-2575
US

IV. Provider business mailing address

PO BOX 18463
ANAHEIM CA
92817-8463
US

V. Phone/Fax

Practice location:
  • Phone: 562-413-5216
  • Fax:
Mailing address:
  • Phone: 562-413-5216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JESSE COOK
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 951-675-8198