Healthcare Provider Details

I. General information

NPI: 1881413573
Provider Name (Legal Business Name): MR. TEDDY COLLINS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2024
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

536 W. VISTA WAY
VISTA CA
92083
US

IV. Provider business mailing address

536 W. VISTA WAY
VISTA CA
92083
US

V. Phone/Fax

Practice location:
  • Phone: 760-758-1650
  • Fax:
Mailing address:
  • Phone: 760-758-1650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-PFGARE
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: