Healthcare Provider Details

I. General information

NPI: 1689868010
Provider Name (Legal Business Name): PRIME HEALTHCARE PARADISE VALLEY HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2007
Last Update Date: 03/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 RIMBEY AVENUE CLASS ROOM #27
SAN DIEGO CA
92154-3099
US

IV. Provider business mailing address

330 MOSS ST 490 EMORY, IMPERIAL BEACH, CA. 91932
CHULA VISTA CA
91911-2005
US

V. Phone/Fax

Practice location:
  • Phone: 619-628-3541
  • Fax: 619-628-3589
Mailing address:
  • Phone: 619-585-4228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37JW
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number090000086
License Number StateCA

VIII. Authorized Official

Name: JESSICA HANLY
Title or Position: CONTROLLER
Credential:
Phone: 619-470-4233