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General NPI Number Information
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NPI Number | 1396125456
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Entity Type | Organization
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Legal Business Name | VIRTUAL REALITY MEDICAL CENTER
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Dates
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Enumeration Date | 06/04/2015
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Last Update Date | 05/17/2016
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Provider Practice Location Address
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Address Line | 6540 LUSK BLVD STE C115
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City | SAN DIEGO
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State | CA
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Zip | 92121-2767
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Country | US
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Telephone | 858-642-0267
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Fax |
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Provider Business Mailing Address
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Address Line | 6540 LUSK BLVD STE C115
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City | SAN DIEGO
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State | CA
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Zip | 92121-2767
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Country | US
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Telephone | 858-642-0267
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARK D WIEDERHOLD
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Credential | M.D., PH.D., FACP
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Telephone | 858-642-0267
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY16840
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License Number State | CA
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