Healthcare Provider Details

I. General information

NPI: 1417197591
Provider Name (Legal Business Name): NAVAL MEDICAL CENTER SAN DIEGO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2009
Last Update Date: 03/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2446 TRIDENT WAY
SAN DIEGO CA
92155-5494
US

IV. Provider business mailing address

2446 TRIDENT WAY
SAN DIEGO CA
92155-5494
US

V. Phone/Fax

Practice location:
  • Phone: 619-437-0777
  • Fax: 619-437-5248
Mailing address:
  • Phone: 619-437-0777
  • Fax: 619-437-5248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. RANDY N LIGHTCAP
Title or Position: PROVIDER
Credential: IDC
Phone: 619-437-0777