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General NPI Number Information
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NPI Number | 1538669163
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Entity Type | Organization
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Legal Business Name | SGBA DIVERSIFIED INC
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Dates
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Enumeration Date | 02/20/2018
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Last Update Date | 02/20/2018
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Provider Practice Location Address
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Address Line | 5735 KEARNY VILLA RD STE 101
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City | SAN DIEGO
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State | CA
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Zip | 92123-1138
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Country | US
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Telephone | 619-644-2170
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Fax | 619-644-2174
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Provider Business Mailing Address
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Address Line | 5735 KEARNY VILLA RD STE 101
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City | SAN DIEGO
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State | CA
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Zip | 92123-1138
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Country | US
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Telephone | 619-644-2170
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Fax | 619-644-2174
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Authorized Official
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Title or Position | PRESIDENT
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Name | STEPHEN J GRISWOLD
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Credential |
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Telephone | 619-644-2170
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 97888
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License Number State | CA
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