Healthcare Provider Details

I. General information

NPI: 1710606868
Provider Name (Legal Business Name): HALEY FORD ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2022
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2321 MORENA BLVD
SAN DIEGO CA
92110-4136
US

IV. Provider business mailing address

9561 PODELL AVE
SAN DIEGO CA
92123-3636
US

V. Phone/Fax

Practice location:
  • Phone: 510-371-3477
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: