MEDICARE: HALEY FORD ATC

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
1	226300000X	Kinesiotherapist		CA
2	2255A2300X	Athletic Trainer		CA

General Provider Information

NPI Number	:	1710606868
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HALEY FORD ATC

Provider Business Mailing Address
First Line	:	9561 PODELL AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-3636
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2321 MORENA BLVD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92110-4136
Country	:	US
Telephone Number	:	510-371-3477
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2022
Last Update Date	:	08/23/2022

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Directions to “ HALEY FORD ATC” Practice Location

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