Healthcare Provider Details

I. General information

NPI: 1104856111
Provider Name (Legal Business Name): EDNA M AUGUSTINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6035 UNIVERSITY AVE STE 32
SAN DIEGO CA
92115-6343
US

IV. Provider business mailing address

6035 UNIVERSITY AVE STE 32
SAN DIEGO CA
92115-6343
US

V. Phone/Fax

Practice location:
  • Phone: 619-582-9819
  • Fax: 619-582-9820
Mailing address:
  • Phone: 619-582-9819
  • Fax: 619-582-9820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MISS EDNA M AUGUSTINE
Title or Position: OWNER
Credential:
Phone: 619-582-9819