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General NPI Number Information
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NPI Number | 1023762804
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Entity Type | Individual
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Provider Name | CALEB FANEN ICHULL-INGYA
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Gender | Male
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Dates
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Enumeration Date | 02/09/2022
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Last Update Date | 03/27/2023
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Provider Practice Location Address
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Address Line | 8775 AERO DR STE 132
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City | SAN DIEGO
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State | CA
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Zip | 92123-1779
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Country | US
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Telephone | 858-609-8742
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Fax |
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Provider Business Mailing Address
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Address Line | 8775 AERO DR STE 132
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City | SAN DIEGO
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State | CA
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Zip | 92123-1779
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Country | US
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Telephone | 562-414-9764
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State | CA
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