Healthcare Provider Details

I. General information

NPI: 1871160408
Provider Name (Legal Business Name): PACIFIC BEACH HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2021
Last Update Date: 05/02/2024
Certification Date: 05/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2108 GARNET AVE STE A
SAN DIEGO CA
92109-3671
US

IV. Provider business mailing address

2108 GARNET AVE STE A
SAN DIEGO CA
92109-3671
US

V. Phone/Fax

Practice location:
  • Phone: 858-717-4322
  • Fax:
Mailing address:
  • Phone: 858-717-4322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: THOMAS HATHORN
Title or Position: CEO
Credential:
Phone: 858-717-4322