Healthcare Provider Details

I. General information

NPI: 1710136684
Provider Name (Legal Business Name): EDWIN JUANENGO DAYRIT RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2008
Last Update Date: 09/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 LA JOLLA VILLAGE DR
SAN DIEGO CA
92161-0002
US

IV. Provider business mailing address

345 CORTE TROVA
CHULA VISTA CA
91914-4408
US

V. Phone/Fax

Practice location:
  • Phone: 858-552-8585
  • Fax:
Mailing address:
  • Phone: 619-754-3479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number487568
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: