=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457587677
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RADY CHILDREN HOSPITAL AND HEALTHCARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2009
-----------------------------------------------------
Last Update Date | 06/02/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1261 3RD AVE D
-----------------------------------------------------
City | CHULA VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91911-3262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-420-5611
-----------------------------------------------------
Fax | 619-420-5531
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1261 3RD AVE D
-----------------------------------------------------
City | CHULA VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91911-3262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-420-5611
-----------------------------------------------------
Fax | 619-420-5531
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOCIAL WORKER 1
-----------------------------------------------------
Name | MRS. MARIA P CLARK
-----------------------------------------------------
Credential | MSW
-----------------------------------------------------
Telephone | 619-420-5611
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282NC2000X
-----------------------------------------------------
Taxonomy Name | Children's Hospital
-----------------------------------------------------
License Number | ASW16491
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------