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General NPI Number Information
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NPI Number | 1750829487
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Entity Type | Organization
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Legal Business Name | MIRA MESA BUSINESS GROUP LLC
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Dates
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Enumeration Date | 02/01/2017
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Last Update Date | 02/01/2017
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Provider Practice Location Address
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Address Line | 9460 MIRA MESA BLVD SUITE L
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City | SAN DIEGO
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State | CA
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Zip | 92126-4851
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Country | US
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Telephone | 858-863-7246
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Fax | 858-252-2650
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Provider Business Mailing Address
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Address Line | 9460 MIRA MESA BLVD SUITE L
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City | SAN DIEGO
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State | CA
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Zip | 92126-4851
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Country | US
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Telephone | 858-863-7246
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Fax | 858-252-2650
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Authorized Official
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Title or Position | SECRETARY
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Name | DAVIS DUONG
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Credential |
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Telephone | 858-380-7530
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number |
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License Number State |
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