Healthcare Provider Details

I. General information

NPI: 1962018044
Provider Name (Legal Business Name): EXCEL SPINE CENTER A CALIFORNIA MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2020
Last Update Date: 12/12/2022
Certification Date: 12/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6719 ALVARADO RD STE 304
SAN DIEGO CA
92120-5265
US

IV. Provider business mailing address

6719 ALVARADO RD STE 304
SAN DIEGO CA
92120-5265
US

V. Phone/Fax

Practice location:
  • Phone: 619-344-6918
  • Fax:
Mailing address:
  • Phone: 619-344-6918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CHOLL WAN KIM
Title or Position: OWNER
Credential: MD, PHD
Phone: 619-344-6918