Healthcare Provider Details

I. General information

NPI: 1619360120
Provider Name (Legal Business Name): JUDY CAROL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2015
Last Update Date: 07/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3561 QUINCE ST
SAN DIEGO CA
92104-4819
US

IV. Provider business mailing address

3561 QUINCE ST
SAN DIEGO CA
92104-4819
US

V. Phone/Fax

Practice location:
  • Phone: 619-283-5816
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1705
License Number StateCA

VIII. Authorized Official

Name: JUDY CAROL
Title or Position: OCCUPATIONAL THERAPY ASSISTANT
Credential: COTA/L
Phone: 619-325-0154