Healthcare Provider Details

I. General information

NPI: 1841241585
Provider Name (Legal Business Name): PSYCHIATRIC CENTERS AT SAN DIEGO, INC. MED GRP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4542 RUFFNER ST SUITE#200
SAN DIEGO CA
92111-2237
US

IV. Provider business mailing address

PO BOX 609001
SAN DIEGO CA
92160-9001
US

V. Phone/Fax

Practice location:
  • Phone: 619-528-4600
  • Fax: 619-528-4625
Mailing address:
  • Phone: 619-528-4600
  • Fax: 619-528-4625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER MORACHE
Title or Position: PRESIDENT
Credential: MD
Phone: 619-528-4600