Healthcare Provider Details

I. General information

NPI: 1568529147
Provider Name (Legal Business Name): CHILDREN'S SPECIALISTS OF SAN DIEGO - DIV OF CARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8001 FROST ST ENTRANCE 9
SAN DIEGO CA
92123-2746
US

IV. Provider business mailing address

3860 CALLE FORTUNADA SUITE 210
SAN DIEGO CA
92123-4800
US

V. Phone/Fax

Practice location:
  • Phone: 858-966-5855
  • Fax:
Mailing address:
  • Phone: 858-309-6303
  • Fax: 858-309-6301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: HERBERT C. KIMMONS JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 858-966-8567