Healthcare Provider Details

I. General information

NPI: 1225590300
Provider Name (Legal Business Name): MR. JOAQUIN A BURGOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 04/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 RANCHEROS DR STE 166
SAN MARCOS CA
92069-2980
US

IV. Provider business mailing address

340 RANCHEROS DR STE 166
SAN MARCOS CA
92069-2980
US

V. Phone/Fax

Practice location:
  • Phone: 760-744-3672
  • Fax: 760-744-6182
Mailing address:
  • Phone: 760-744-3672
  • Fax: 760-744-6182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: