Healthcare Provider Details

I. General information

NPI: 1922457696
Provider Name (Legal Business Name): QUALITAS MOBILE MEDICAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2016
Last Update Date: 06/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8787 COMPLEX DR 130
SAN DIEGO CA
92123-1419
US

IV. Provider business mailing address

7660 FAY AVE #329
LA JOLLA CA
92037-0021
US

V. Phone/Fax

Practice location:
  • Phone: 619-882-3100
  • Fax: 858-278-9818
Mailing address:
  • Phone: 858-829-1921
  • Fax: 619-269-4362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY SCOTT WILLMANN
Title or Position: PRESIDENT & CEO
Credential: MHSA
Phone: 858-829-1921