Basic Information
| Provider Information | |||||||||
| NPI: | 1548495674 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GERARDO | ||||||||
| FirstName: | GERI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1202 MORENA BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921103844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192750822 | ||||||||
| FaxNumber: | 6192751422 | ||||||||
| Practice Location | |||||||||
| Address1: | 2865 LOGAN AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921132411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192324357 | ||||||||
| FaxNumber: | 6192327048 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2009 | ||||||||
| LastUpdateDate: | 03/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | VN707760 | CA | Y | Nursing Service Providers | Licensed Vocational Nurse |
ID Information
| ID | Type | State | Issuer | Description | 1588617955 | 01 | CA | CLINIC NPI | OTHER | HAP70530F | 05 | CA | MEDICAID | FHC70530F | 05 | CA | MEDICAID |