Healthcare Provider Details

I. General information

NPI: 1790088219
Provider Name (Legal Business Name): SITI MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2010
Last Update Date: 12/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1951 4TH AVE STE 202
SAN DIEGO CA
92101-2374
US

IV. Provider business mailing address

1951 4TH AVE #202
SAN DIEGO CA
92101
US

V. Phone/Fax

Practice location:
  • Phone: 619-717-8484
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number18150
License Number StateCA

VIII. Authorized Official

Name: MS. SUSAN ANN KINCAID
Title or Position: PART OWNER/ MANGER
Credential: FNP
Phone: 619-717-8484