Healthcare Provider Details

I. General information

NPI: 1124307970
Provider Name (Legal Business Name): GET WELL STAY WELL MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2011
Last Update Date: 01/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1945 GARNET AVE
SAN DIEGO CA
92109-3595
US

IV. Provider business mailing address

1945 GARNET AVE
SAN DIEGO CA
92109-3595
US

V. Phone/Fax

Practice location:
  • Phone: 858-224-7977
  • Fax: 858-224-7978
Mailing address:
  • Phone: 858-224-7977
  • Fax: 858-224-7978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number20A5441
License Number StateCA

VIII. Authorized Official

Name: DR. KENNETH L. ANDERSON III
Title or Position: CEO
Credential: D.O.
Phone: 858-224-7977