Healthcare Provider Details

I. General information

NPI: 1376165688
Provider Name (Legal Business Name): SAN DIEGO CENTER FOR RECREATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2020
Last Update Date: 05/08/2020
Certification Date: 05/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4535 QUANTICO AVE
SAN DIEGO CA
92117-3831
US

IV. Provider business mailing address

PO BOX 17369
SAN DIEGO CA
92177-7369
US

V. Phone/Fax

Practice location:
  • Phone: 858-882-7872
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEANNETTE M GILMORE
Title or Position: OWNER
Credential: LMFT
Phone: 858-882-7872