Healthcare Provider Details

I. General information

NPI: 1487221008
Provider Name (Legal Business Name): VARSITY TEAM, INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2021
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8745 BENNINGTON ST
SAN DIEGO CA
92126-3221
US

IV. Provider business mailing address

PO BOX 26633
SAN DIEGO CA
92196-0633
US

V. Phone/Fax

Practice location:
  • Phone: 858-860-5332
  • Fax:
Mailing address:
  • Phone: 619-694-6809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: DREW DAHLSTEDT
Title or Position: CFO/COO
Credential:
Phone: 619-694-6809