Healthcare Provider Details

I. General information

NPI: 1619426673
Provider Name (Legal Business Name): PACIFIC MEDICAL/BAY RECOVERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2016
Last Update Date: 04/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 5TH AVE STE 200
SAN DIEGO CA
92101-3224
US

IV. Provider business mailing address

1501 5TH AVE STE 200
SAN DIEGO CA
92101-3224
US

V. Phone/Fax

Practice location:
  • Phone: 619-493-0436
  • Fax:
Mailing address:
  • Phone: 619-493-0436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberIMF78197
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: JOSIE RAMOS
Title or Position: HR MANAGER
Credential:
Phone: 619-592-8695