=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871953604
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAN DIEGO RESCUE MISSION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2016
-----------------------------------------------------
Last Update Date | 03/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 ELM ST
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92101-2602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-819-1882
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 80427
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92138-0427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | NATHANIEL BUGGS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 619-819-1882
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------