Healthcare Provider Details

I. General information

NPI: 1346811882
Provider Name (Legal Business Name): DESTINATIONS DIRECT PRIMARY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2021
Last Update Date: 07/06/2021
Certification Date: 07/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

338 VIA VERA CRUZ STE 100
SAN MARCOS CA
92078-2645
US

IV. Provider business mailing address

338 VIA VERA CRUZ STE 100
SAN MARCOS CA
92078-2645
US

V. Phone/Fax

Practice location:
  • Phone: 304-741-3523
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN C NEELY
Title or Position: MD/CEO
Credential: MD
Phone: 304-741-3523