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General NPI Number Information
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NPI Number | 1093783045
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Entity Type | Organization
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Legal Business Name | SOUTHBAY NEUROLOGICAL MED GR
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Dates
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Enumeration Date | 03/08/2006
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Last Update Date | 03/18/2014
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Provider Practice Location Address
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Address Line | 360 H ST
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City | CHULA VISTA
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State | CA
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Zip | 91910-5511
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Country | US
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Telephone | 619-585-7227
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Fax | 619-585-3190
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Provider Business Mailing Address
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Address Line | 360 H ST
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City | CHULA VISTA
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State | CA
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Zip | 91910-5511
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Country | US
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Telephone | 619-585-7227
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Fax | 619-585-3190
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | BLANCA GAMBOA
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Credential | CPC
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Telephone | 619-585-7227
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 2084N0400X
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License Number State | CA
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