Healthcare Provider Details

I. General information

NPI: 1184157208
Provider Name (Legal Business Name): SAN DIEGO REHAB AND FITNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2017
Last Update Date: 04/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4184 MADISON AVE
SAN DIEGO CA
92116-4709
US

IV. Provider business mailing address

4184 MADISON AVE
SAN DIEGO CA
92116-4709
US

V. Phone/Fax

Practice location:
  • Phone: 619-736-0506
  • Fax:
Mailing address:
  • Phone: 619-736-0506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number
License Number State

VIII. Authorized Official

Name: SHAWNA NORTON
Title or Position: FOUNDER/CEO
Credential:
Phone: 619-379-6680