Healthcare Provider Details

I. General information

NPI: 1912404609
Provider Name (Legal Business Name): ERIK KOLBERG BCO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 04/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9663 TIERRA GRANDE ST STE 201
SAN DIEGO CA
92126-4570
US

IV. Provider business mailing address

9663 TIERRA GRANDE ST STE 201
SAN DIEGO CA
92126-4570
US

V. Phone/Fax

Practice location:
  • Phone: 858-695-2021
  • Fax: 858-695-2712
Mailing address:
  • Phone: 858-695-2021
  • Fax: 858-695-2712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1700X
TaxonomyOcularist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: