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NPI Code Detail

MEDICARE: DOMINICAN MEDICAL FOUNDATIONS MISSION ST.

MEDICARE: DOMINICAN MEDICAL FOUNDATIONS MISSION ST.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1332900000XNon-Pharmacy Dispensing SiteA88194CA

General Provider Information

NPI Number : 1275780603
Entity Type Code : Organization
Provider Name (Legal Business Name) : DOMINICAN MEDICAL FOUNDATIONS MISSION ST.
Provider Business Mailing Address
First Line : 5626 OBERLIN DR
Second Line : SUITE 110
City : SAN DIEGO
State : CA
Zip : 92121-1705
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2018 MISSION ST
Second Line :
City : SANTA CRUZ
State : CA
Zip : 95060-5218
Country : US
Telephone Number : 831-706-2220
Fax Number :
Authorized Official
Title or Position : DIRECTOR OF OPERATIONS
Name : KENNY HEINE
Credential :
Telephone Number : 858-625-2990
Provider Enumeration Date : 08/27/2008
Last Update Date : 10/23/2012

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