Basic Information
| Provider Information | |||||||||
| NPI: | 1659606200 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORE SAN DIEGO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1080 MARINA VILLAGE PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ALAMEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945016427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103377950 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1675 MORENA BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921103703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192758000 | ||||||||
| FaxNumber: | 6192758004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2009 | ||||||||
| LastUpdateDate: | 10/14/2009 | ||||||||
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| AuthorizedOfficialLastName: | LANGFELD | ||||||||
| AuthorizedOfficialFirstName: | MARSHALL | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP CFO | ||||||||
| AuthorizedOfficialTelephone: | 5103377950 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TELECARE CORPORATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.