=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780122986
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LA JOLLA OBSERVATION MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2017
-----------------------------------------------------
Last Update Date | 01/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9888 GENESEE AVE
-----------------------------------------------------
City | LA JOLLA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92037-1205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-626-6150
-----------------------------------------------------
Fax | 626-623-1227
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9888 GENESEE AVE STE LJ-105
-----------------------------------------------------
City | LA JOLLA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92037-1205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-824-6742
-----------------------------------------------------
Fax | 858-824-7989
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING LIASON
-----------------------------------------------------
Name | TAYLOR Y. CARDALL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 858-626-6902
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------