Healthcare Provider Details

I. General information

NPI: 1063683357
Provider Name (Legal Business Name): GORDON M RICK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2008
Last Update Date: 06/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5190 GOVERNOR DR SUITE 106
SAN DIEGO CA
92122-2847
US

IV. Provider business mailing address

5190 GOVERNOR DR SUITE 106
SAN DIEGO CA
92122-2847
US

V. Phone/Fax

Practice location:
  • Phone: 858-784-0600
  • Fax: 858-784-0604
Mailing address:
  • Phone: 858-784-0600
  • Fax: 858-784-0604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberCLF11078
License Number StateCA

VIII. Authorized Official

Name: DR. GORDON MARVIN RICK
Title or Position: OWNER/DIRECTOR
Credential: DDS
Phone: 858-784-0600