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General NPI Number Information
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NPI Number | 1659453769
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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 | 10/19/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 6160 CORNERSTONE COURT EAST STE 155
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City | SAN DIEGO
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State | CA
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Zip | 92121
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Country | US
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Telephone | 858-642-0267
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Fax | 858-642-0285
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Provider Business Mailing Address
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Address Line | 6160 CORNERSTONE COURT EAST STE 155
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City | SAN DIEGO
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State | CA
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Zip | 92121
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Country | US
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Telephone | 858-642-0267
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Fax | 858-642-0285
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. MARK WIEDERHOLD
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Credential | PHD MD 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 | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | G66151
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License Number State | CA
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