=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508139189
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CECILIO EMANUEL CROSBY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2012
-----------------------------------------------------
Last Update Date | 09/17/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 319 F ST SUITE 205
-----------------------------------------------------
City | CHULA VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91910-2666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-746-6978
-----------------------------------------------------
Fax | 619-779-7081
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 319 F ST SUITE 205
-----------------------------------------------------
City | CHULA VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91910-2666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-746-6978
-----------------------------------------------------
Fax | 619-779-7081
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. CECILIO EMANUEL CROSBY
-----------------------------------------------------
Credential | N/A
-----------------------------------------------------
Telephone | 619-746-6978
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------