Healthcare Provider Details

I. General information

NPI: 1912886490
Provider Name (Legal Business Name): MR. MICHAEL ANGELO PEPPERS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2025
Last Update Date: 11/20/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5473 KEARNEY VILLA RD STE 300
SAN DIEGO CA
92123-9212
US

IV. Provider business mailing address

5473 KEARNY VILLA RD STE 300
SAN DIEGO CA
92123-1142
US

V. Phone/Fax

Practice location:
  • Phone: 858-298-7347
  • Fax: 619-684-7004
Mailing address:
  • Phone: 858-298-7347
  • Fax: 619-684-7004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number22900
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: