Healthcare Provider Details

I. General information

NPI: 1265737829
Provider Name (Legal Business Name): PUENTE DE VIDA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2011
Last Update Date: 01/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4747 MORENA BLVD SUITE 258
SAN DIEGO CA
92117-3465
US

IV. Provider business mailing address

PO BOX 86020
SAN DIEGO CA
92138-6020
US

V. Phone/Fax

Practice location:
  • Phone: 858-452-3915
  • Fax:
Mailing address:
  • Phone: 858-452-3915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: CAROL SCHAEFER
Title or Position: VICE-PRESIDENT
Credential:
Phone: 858-452-3915