Healthcare Provider Details

I. General information

NPI: 1033235718
Provider Name (Legal Business Name): RADY CHILDREN'S HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 CHILDRENS WAY MC 5014
SAN DIEGO CA
92123-4223
US

IV. Provider business mailing address

3020 CHILDREN'S WAY MC 5014
SAN DIEGO CA
92123-4282
US

V. Phone/Fax

Practice location:
  • Phone: 858-966-4011
  • Fax: 858-278-2365
Mailing address:
  • Phone: 858-966-4011
  • Fax: 858-278-2365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 14677
License Number StateCA

VIII. Authorized Official

Name: MR. CHARLES WILSON
Title or Position: DIRECTOR
Credential: MSW
Phone: 858-576-1700