Healthcare Provider Details

I. General information

NPI: 1710658885
Provider Name (Legal Business Name): ABDIKADIR DIRIYE RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2021
Last Update Date: 09/27/2021
Certification Date: 09/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 COMMERCIAL ST
SAN DIEGO CA
92113-1283
US

IV. Provider business mailing address

2401 COMMERCIAL ST
SAN DIEGO CA
92113-1283
US

V. Phone/Fax

Practice location:
  • Phone: 619-739-0228
  • Fax:
Mailing address:
  • Phone: 619-739-0228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2279C0205X
TaxonomyCritical Care Registered Respiratory Therapist
License Number26896
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: