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General NPI Number Information
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NPI Number | 1669596557
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Entity Type | Organization
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Legal Business Name | COLONIAL CORNER MEDICAL GROUP, INC.
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Dates
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Enumeration Date | 03/18/2007
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 4440 EUCLID AVE # C
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City | SAN DIEGO
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State | CA
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Zip | 92115-4522
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Country | US
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Telephone | 619-582-5105
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Fax | 619-582-5121
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Provider Business Mailing Address
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Address Line | 4440 EUCLID AVE # C
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City | SAN DIEGO
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State | CA
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Zip | 92115-4522
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Country | US
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Telephone | 619-582-5105
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Fax | 619-582-5121
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Authorized Official
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Title or Position | FINANCE MANAGER
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Name | MRS. ELIZABETH DAVID I
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Credential |
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Telephone | 619-582-5105
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | G86752
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License Number State | CA
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